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On Joaquin County *cE "— <br /> Environmental3 � Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 JUL 1 I N91'IGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehiNVIRUNMfNT HEl #T IV <br /> ' " Well Permit Application PERMIT/SERVICE-2- <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 /> ,4�jG"nf tg y Assessors YJ <br /> WELL Location „ �./ Fee M61�L SYCross Street itys%af p '1 Zip9 Parcel# �w <br /> PROPERTY /, Q <br /> Owner (il�14tSon Address C.,1 ` City Ack Zip4_�Phone# <br /> C-57 Contractor Re-60n Q.So itSiB air.Address;= /V. 12161 sl • Citywm p �Lic#M2Z33qPhone g <br /> Consultant/Sub Cntra&TI' 11C• Address 64•Vh CiV50 Lic# Phone - b� <br /> GIS Coordinates'407657.33l ,YVII1.1`19. ZO$ TownshiPpKwY Range Section <br /> WORK TO BE PERFORMED: <br /> EW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> OIL BORING# 1 0 OVER-BORE. DIAMETER <br /> 0 WELL# AU/ 0 PRESSURE GROUT <br /> �Z <br /> 0*Other GROUT SPECIFICATIONS <br /> • COMMENTS: <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 /> a 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: 'a AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE VUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> BOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS t+ <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 26 •t e 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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County rdinance Rules and Regulations, and all applicable California State Laws. <br /> Signed11 rr c.w Title/Company V �� cQ l�� :A <br /> M:A <br /> Print Na 1..UL l S X \R.AM C-E U(- Date <br /> DEPARTMENT USE ONLY ► Z�59 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued • Area <br /> Grout Inspection By Date Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DAT PERMIT/SERVICE REQUEST# INVOICE <br /> 1610/ B Zo 7/I/ ob S R# pp <br /> C-571WC ;/-WAIVER— C-57 Letter of Authorization to si n permit Encroachment doc--;ff-; <br /> EHD 29-02-001 70/ <br /> 6/22/04 � Aok <br />