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�o ul �Q , .,an Joaquin County <br /> z Environmental Health Department SITE <br /> { 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 JAN - 7 ?.00hfiITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.orRONMEiVT HEAUMNIT IV <br /> Well Permit Application PERMIT/SERVICES <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 /> eayt I)- :''tum o-tiJxj..ce t- 7Yljj, "54 ST. G1nz'rd la.'4t Assessors <br /> WELL Location 1 v '1(2zz ��,� �� �k�,•Cross Street #-1✓d City �' e-k fyti Zip Parcel# Ile ' l- oo) <br /> PROPERTY <br /> Owner Ccts+ g,.,, /14 L4 r Address 45)'q Vj-11-,h 5£. City��� Zip`2�Phone# 209-qy6--gOot) <br /> C-57 Contractor /V//Of- Address City Zip__— Lic# - Phone# <br /> .T <br /> Consultant/Sub Cntr SEL o k +�t, Address 3yr-7 KN2 A'e City a--_d-,Fri Lic# Phone# 9"(6--f?-61-090V <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNHAND-AUG OTHER") Q DESTRUCTION (choose type below) <br /> SOIL BORING#I a; 14- 2 i4-iC 3/f-G 0 OVER-BORE. DIAMETER <br /> p WELL# p PRESSURE GROUT <br /> Q`Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS N <br /> MONITORING a HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS <br /> Q MULTI-LEVEL WELL CASING DIA: <br /> EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL Q PVC a OTHER: <br /> P VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL IATA TREMIE TYPE TO BE USED: a AUGERS a HOSE �r <br /> R SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes rNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING ' tAND AUGER GROUT SPECIFICATIONS i A <br /> Il OTHER: (0 OTHER APPROX.BORING DEPTH <br /> BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED(if YES,list specifications in comment section) <br /> COMMENTS:_ 1 5 O�A ID.n r`,"c an�itl7C t0 C.,tf�ec f- 9 ru(a d ryc{r.,Qwa <br /> c7M <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. 3 <br /> 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. <br /> Signed x_ ���c+_�-•--•� s�- .� / S <br /> Title/Company_ u �c�ps`5{ f J ���� mow'{ = <br /> Print Name Date 12-11310q <br /> { <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS:_ ��,27 �a, Vim.u c ' <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued t`( �.4/0�- Area _ <br /> Grout Inspection By Date 3j D Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS:__ Lo <br /> ACCOUNTING ONLY: AID# FAC# <br /> 'CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3Soc 8�" �5 ` 6o87S'y l EDF SR#15reve 6 88 <br /> C-57_ WC--WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />