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oaa,� San Joaquin County <br /> 2 - ? Environmental Health Department SITE <br /> , <br /> N: � •� 304 East Weber Avenue,3rd Floor, Stockton, CA 9520 ��Mr ATION <br /> UNIT IV <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> . ,c9 . , a`P• 1 6 nn <br /> /FaR Well Permit Application ����yyMAY <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEt1`vr HENT HEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. T IIUSERi5V{( g in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> �� Assessors <br /> � <br /> WELL Location /7�B6 �x"'r`^' �� Cross Stree;/dui—City zip 9S53J Parcel# <br /> PROPERTY ,,/ <br /> Owner/c+noOt�l`�I-G n ' Address <br /> � 12Ocity ,Zip Phone#L <br /> C-57 ContractorAddress 1,9, fiy11d// city Zip_ Lic# P'hone�&Z-4'y ��Y <br /> Consultant/Sub Cntr /le/NAddress,yl�hYe74F City .Li <br /> Phone#5!Pr � <br /> GIS Coordinates:X ,Y .Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL I BORING (CPT,GEOPROB YDROPUNCH, AND-AUGER,OTHER*) b DESTi�UCTION (choose type below) <br /> o SOIL BORING# a OVER-PORE. DIAMETER <br /> n WELL# a PRESSURE GROUT <br /> 51/0therT GROUT SPECIFICATIONS <br /> COMMENTS: ACG-7�+ -s --- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING I]HOLLOW STEM DIA.OF BOREHOLE_ a MULTIPLE CASINGS n MULTI-LEVEL WELL CASING DIA: <br /> o EXTRACTION n AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASINGi O STEEL O PVC O OTHER: <br /> n VAPOR n MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS n HOSE <br /> AIR SPARGE/OZONE2qUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> n SOIL BORING n HAND AUGER GROUT SPECIFICATIONS G - "; <br /> ;hJDTHER:2& J a OTHER APPROX.BORING DEPTH_ /"S �' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> b�(C.-J-�4U h L CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: � 02�9 �ar�kr tee"' <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 Ordinance ul and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company G-e64 <br /> Print Name Dat <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRES : 1 b <br /> WORK PLAN DATED: <br /> Application Accepted By r " L Dale Issued -5 <br /> IUB Area&-, _ <br /> Grout Inspection By 1i•( rDale,rt/2OS Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK If RECD BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> SR# E <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 />