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�o UI San Joaquin County <br /> r % Envimental Health Departmento ITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br /> ., � <br /> (209)468-3449 Fax: (209)468-3433 Web: www,sjgov.org/ehd ATIONUNIT IV <br /> p0I�R Well Permit Application AUG v ) 2005 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENT HEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This pplM�tl���`ri�'a'd� r't'compliance with San <br /> Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> t Assessors <br /> WELL Location G �_ Cross Street �. City_ Si,c,c��o. _Zip SZo� Parcel# 9-OLt <br /> PROPERTY /r <br /> Owner Main S{�,� Coco_ Address O Wk; rr City ) Zip Phone# Z'js �'f.3`2D2Q <br /> C-57 Contractor r Address a City Zip 53 Lic# Phone#-rT251313-5$Q^� <br /> Consultant I Sub Cntr_A&E. City S{t m _Lfc# Cb22. Phone#_(2nq)y�7-�eoCe <br /> f! <br /> GES Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> EW WELL/BORING (CP EOPROBE,HYDROPUNCH,HAND-AUGER,OTHF�R") 0 DESTRUCTION (choose type below) <br /> SOIL BORING# �� C_PT-,3, CPT-S �t( 66, gS d OVER-BORE. DIAMETER <br /> WELL# J <br /> 0"other 0 PRESSURE GROUT { <br /> GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> II MONITORING j]HOLLOW STEM DIA-OF BOREHOLE 2, " MULTIPLE CASINGS 4k <br /> 0 EXTRACTION ©AIR HAMMER/DRIVEN CASING THICKNESS ,� 0 MULTI-LEVEL WELL CASING DIA: <br /> r TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: vt a <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUTS EAL I OCZ . TREMIE TYPE TO BE USED: B-AGGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0-15"USH POINT(GP or CP GROUT SEAL PUMPED: 0 Yes e-N'o (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ff SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> #I OTHER; 0 OTHER APPROX. BORING DEPTH Ion 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED a (if YES,list specifications in comment section) <br /> COMMENTS: <br /> i <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> t <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin ' <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws, j <br /> Signed ze '_7� <br /> /�,/ Title/Company t � J4G� <br /> -� <br /> Print M. Date <br /> 8-30 —0 S_ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 16"152�0 <br /> WORK PLAN DATED-: // L7u--, 05 <br /> �t/� f <br /> Application Accepted By_ di y-� -�r1�•'+ Date Issued_ !�_�15G led /y53 <br /> Area , <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> FACCTOUNTING ONLY: AID# <br /> FAC# <br /> FEEINFO AMOUNTREMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> -x-79 ZZ 75. 2 SR# 00Lf3735 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br /> HHD 29-02-001 r <br /> 6/22704 <br />