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*Okz San Joaquin CountyEnvh amental Health De artmentr�pJl 't1304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 - � H GATION <br /> (209) 468-3449 Fax : (209) 468 -3433 Web: www. sjgov. org/ehdL � , ,105 UNIT IV <br /> Well Permit Application <br /> E(vu " 1 � 1 _ i=III IFA!M <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED OF1 , 1 _ , Ilei -I (, L_ s <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 <br /> Joaquin County Development Title , Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> JJ S ! Assessors <br /> WELL Location �,� �oc,. nj G�r..� Cross Street City a M Zip S .52CLI parcel# 12 .5_ 020 - / Z <br /> PROPERTY qq <br /> Owner_' nyviol `joove^� Address 5F 1 YgnG(jO t/01 (G11<dcity_ (.,.� �w� �< rp 72/5*0a#_ /%j <br /> C-57 Contr✓✓actor RJ 'e9d'd,]is <br /> ��i ��. Addr€ss 4,50 /{o �.r ,c;. r.� City /'Iw /f nGiZip 9r5'" ic# yX Phone# 9Z5-313 "6gU0 <br /> 11 II p� I � r � 9SV7 (. <br /> Consultant / Sub Cnlr�4,,4ir, Cin✓Peron/Ae^ a Address L7o10erA .;ns SkeeC cityon Lic# Phone# 701 - Y33z367 <br /> GIS Coordinates: X Y , Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL I BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br /> U SOIL BORING # 0 OVER-BORE. DIAMETER <br /> !KWELL # M1✓- SgF MV- IG. NV - l'l . /1 � � 1 F 0 PRESSURE GROUT <br /> D Other ��� GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ;K <br /> MONITORING STEM DIA. OF BOREHOLE D rr �/ <br /> ^nONITORING <br /> "" <br /> N � - 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 17 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS ScG Vo TYPE OF CASING : 0 STEEL X, PVC U OTHER: ay <br /> 1] VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 1-(O / TREMIE TYPE TO BE USED: $AUGERPrLIHOSE <br /> 0 AIR SPARGE/ OZONE a PUSH POINT (GP or CPT) GROUT SEAL PUMPED: U /Yes No (NOTE : MAXIMUM FREE-FALL DEPTH IS 307) <br /> a SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS / ob Lj A & (fe Le ' � <br /> a OTHER:_0 OTHER APPROX. BORING DEPTH ZS ,XBOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED btO (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 Ordinances , ul d R Mations, and all applicable California State Laws. r�1��// <br /> Signed x / Title/CompanyCXWa&4/!S ///f/A <br /> Print Name , LI Date <br /> DEPARTMENT USE ONLY <br /> III SITE MAP IN UNIT IV FILE, ADDRESS : -15'� j 4 r" <br /> WORK PLAN DATED : <br /> Application Accepted By Date Issued Area X60 <br /> Grout Inspection By Date Final Inspection Date <br /> Destruction Inspection By Date <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 /> 35n vJ 2� sR# OD Sid <br /> C-57_ WC= WAIVER_ C-57 Letter ofnALut� h� o� ri tion to �sign <br /> , pier-mit • / Encroachment doc 4# <br /> EHD 29-02-001 eA4w O <br /> 6/22/04 <br />