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Pq"•" an Joaquin County <br /> •�� Envi nmental Health Department ��,, ��. SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 952016;.Y '/C ' 1ITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgoN aphd f or UNIT IV <br /> •v••• N`P <br /> OR Well Permit Application <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 /> l� Assessors <br /> WELL Location 2� .St' o Cross Street ( City Zip��2 `Z Parcel# 7 �� <br /> PROPE , 1—/� �h Z"f <br /> Owner �G�+�h 1 L�uYc Addr{{essr X, City Zip�cL hone#�( <br /> C-57 Contractor L o� 15+41%nress ob( Lt I =VIAAyQ,city �UZip 2;'J tic#5/t)oi I Phone#_/Uq-90 -2(i33 <br /> Consultant/Sub Cntr 7l, RfMCA ct I 1 QVI AddressUt 0(IICS FA UA ity� OSe�t I I4ic# Phone#cltW 19 2-O,7bc7 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> EW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER") 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> or`Othera iUSpUVi1e 6 -QUA a Well GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING ��--rr,,OLLOW STEM DIA.OF BOREHOLE I I <br /> .�W� 11-- 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSSGVI q0 TYPE OF CASING: 0 STEEL �VC flOTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ­7_30' TREMIE TYPE TO BE USED: 0 AUGERS ;ROSE <br /> WIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM IFREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS CeV?1w 17 Uy C'i <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH rj b--`7 6 ,g-60LTED 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 Ordina ces, RuI s and Regulations, and all applicable California State Laws. <br /> Signed Title/Company eSS -v( C0(d ( �W,,, <br /> i <br /> Print Name Ot pV 01 0-C Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED:_CU✓ k)ac�r ",d C_ <br /> Application Accepted By Date Issued 07_y/P Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: Ll ck 70 rruc -- Cf'( OJ e 'll. /�1�+r►+ <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> d-` of SSS7 Z AIL ( o i SR# p0tf2 7 g3 <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 />