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an Joaquin County <br /> Envircottmental Health Department S W�VITE304East Weber Avenue, 3rd Floor, Stockton,CA 95202ATION <br /> (209)468-3449 Fax: (209) 468-3433 Web: vrww.sjgov.org/ehd UNIT IV <br /> , x 7006 <br /> Well Permit Application , ,_ <br /> Co P YEIV1,li?�?��ivlciV f HEALTH <br /> N-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES <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 /> ,'" <br /> Assessors <br /> WELL Location,3 230 IU-(,Nisi`10A1 Cross Street 10-11e VG City Zip g52yy Parcel# 11 2-040'1 � <br /> PROP / <br /> Owner0Q-QbL 'bl'1 Address59.5jJ5/KKS}�yjp p� City ��fbG�'1II7�t Zip JAZ/0 Phone#Zvi-y 74931 <br /> C-57 Contractor1' <br /> {� r(l � <br /> �� Address X43 —OM& t✓dC City Q&�Cdy 'z Zip Z Lic# I� 10 Phone#g!/[- li 38 -! !2 p <br /> Consultant/Sub CntrU/4nredG (A4fX ddress 3 S11�{) rcC) City D& _Lic#fa&Ql21 Phone#�D�-jk7 -100(Q <br /> GIS Coordinates:X Y Township 1 4J Range ((1� Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/ BORING (CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER*) DESTRUCTION (choose type below) <br /> 0 SOIL BORING# OVER-BORE. DIAMETER 111 q <br /> 0 WELL# PRESSURE GROUT �9 <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: ' � f r � , <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 TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 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 /> 1 here4celthat I have prepared this application and that the work will be done in accordance with San Joaquin <br /> Countces, Rules and Regulations, and all applicable CaliforniaaState LawsP y C7>�(9f$ �SSigned Title/Com anIV A <br /> Print NaY� Q�1t' s Date—.31/ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 3Z 3 0 Nor+} Vtl es-r Lan e <br /> WORK PLAN DATED: M a rCL 13 200(, <br /> Application Accepted By V}G I r i L, M e C_ r i n eZj Date Issued 3 Z4 I o l Area_1 4 5 9 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Yi`c`}GT i (, M" L, Date 3`30 -O L <br /> COMMENTS/CONDITIONS: + r 'rL <br /> ACCOUNTING ONLY: AID# F <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3503279 339, DLJ SR# 00 46 <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 />