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qr <br /> - �, an Joaquin CFILE COPY <br /> ounty o <br /> Environmental Health Department <br /> V � E <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br /> 'f ( ) aqY Y <br /> (209)468-3449 Fax: 209 468-3433 Web: www.sjgov.org/ehd %1GATION <br /> � NIT IV <br /> Well Permit Application EI .RONME <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PE R4 !T''FRt/ICIEST <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San 6` <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> G' ►h, N4 Y)RoV`'.e 'W1 <br /> WELL Location_� ,j(;fir fU ( LIV) Cross Street �))1SS Assessors <br /> d� City�� �GYI Zip c` aC Parcel# I a.�^1'i(-dc) <br /> PROPERTv 11�tz;zl tcY� �vz. <br /> Owner— <br /> ti Cc f ,Address�,(1, 1 City- � Zi l) *54- Phone# 0 <br /> C-57ContractorAC1kVvFCA <br /> 1:1 <br /> P � Phone <br /> Consultant/Sub Cntr if Address it <br /> City ' Lic# r` Phone# <br /> GIS Coordinates:X Y Township Range 9 Section <br /> WORK TO BE PERFORMED• <br /> Q NEW WELL/BORI (CPT,GE PROBE,HYDROPUNCH,HAND-AUGER,OTHER*) Q DESTRUCTION (choose type below) <br /> SOIL BORING <br /> Q WELL# Q OVER-BORE. DIAMETER <br /> — <br /> a*Other C5 Q PRESSURE GROUT <br /> COMMENTS: GROUT SPECIFICATIONS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING Q HOLLOW STEM DIA.OF BOREHOLE (.ai'10 MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS A/a TYPE OF CASING: Q STEEL Q PVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL T1)_TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> Q AIR SPARGE/OZONE ` PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes No (N TE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> (SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS Cc% , C" <br /> Q <br /> OTHER:_0 OTHER APPROX.BORING DEPTH «�uo of f id ` <br /> Q OLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: (,f1 i i <:r z\r i 4-- <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County_Qr-ginances, Rules and Regulations,and all applicable California State Laws. <br /> Signed xTitlelCom an �C <br /> r^ T" P Y <br /> jt <br /> Print Name_ fl�1V\l7l_, c- � X '�� Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: R. <br /> WORK PLAN DATED: Q Iu O 5 <br /> Application Accepted By Date Issued / Are-D6 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By 4 Date <br /> COMMENTS/CONDITIONS: O� <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc 65 <br /> Exp 29-02-001 <br /> 6122/04 <br />