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aa� <br /> ,. ..�� San Joaquin Cn-mty, FILE 1j' !2 P Y <br /> y` Environmental Health Department o r <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br /> 209 468-3449 F �� --' N <br /> ( ) ax. (209)468-3433 Web: www.sigov.org/ehd UNIT IV <br /> W � 2005 <br /> ell Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED EN %ONUENT HEALT(i <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applic'afrdrlULTaBlywel isnce with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location c�b Assessors <br /> _ r C ldni i� C u r Cross Street_X I—,t cJ� City "L(,k t7,V'A Zip���04 Parcel#/a 3 Oa <br /> PROPER Y � • �5 <br /> Owner .,0--:AeA C Idzt Addresses jC'` -`C (�t apt City(n;!.� Zip`'Phone# <br /> C-57 Contractor 61 IY'i Loll(- n Address ��`jy1�. � City � �Zip'i:5�Lic# o C) Phone#_QL}Li(n)`! ,jL <br /> Consultant/Sub Cntr Address rt City " Lic# A Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> SOIL BORING# y"� OVER-BORE. DIAMETER <br /> 0 WELL# <br /> a PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE � 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS <br /> A-_TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTA DEPTH OF GROUT SEAL—i � TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> 0 AIRS PARGE/OZONE PUSH POIV(GPr CPT)GROUT SEAL PUMPED: 0Yes RNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> `RSOIL BORING 0 HAND AUGROUT SPECIFICATIONS <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH jgo f <i O` 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <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 dinances, Rules and-Regulations,and all applicable California State Laws. <br /> Signed x Title/Company_��(� -F �1e{� K S-t-y ( } <br /> Print Narne '5e>c Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 1F516 <br /> WORK PLAN DATED: O <br /> Application Accepted By Date Issued � 2-4C) <br /> Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By jrDate <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> -2.e^� 47-12 nuo. � J``��l 8 S R# � 2 tll j} <br /> C-57 WC=WAIVER C-57 Letter of Authorization to sign permit:;wEncroachment doc .� <br /> EHD 29-02-001 <br /> 6/22/04 <br />