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•an Joaquin County • FILEY <br /> Environmental Health Department ( (� 0CEk <br /> E <br /> 304 <br /> { East Weber Avenue, 3rd Floor, Stockton, CA 95202 "LOTION <br /> (209)468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd NIT IV <br /> • c•• 'P <br /> q�'Fotz�� Well Permit Application JUL 1 1 200 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENT HEALTH 0' <br /> PERMIT/SERVI� <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made mpliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location <br /> Assessors <br /> 195O0frcrv�nt 5�, Cross Street urs City D Zip����Parcel# L3W3 ' <br /> PROPERT? n 1 Q r t C1{ / p <br /> Owner-fly 1�1'GCLL 1it1�Ai1Ia.L1h'tddressf 0 3D�'T3� Ci Zip457by Phone#GZd/)l�S 3-g7j�S <br /> C-57 Contractor LuS/ iL Address= IV,15&4 St. CityU��ip 7�Li�hone �3V�Y4i�� <br /> Consultant/Sub CntraY,fh Tr�I,,�rtc, Address/q5 -1C—J1 V6 citV%nLic# Phone#�il�)23Z-241c� <br /> GIS Coordinates:X 417-7"1Q,uI$ Township Range Range Section <br /> Vli RK TO BE PERFORMED: <br /> EW WKL/BORING (CPT, PROBE,HYDROPUNCH,HAND-AUGER,OTHgR*) p DESTRUCTION (choose type below) <br /> SOIL BORING# 111' ;2 1 0 OVER-BORE. DIAMETER <br /> 0 WELL# /]P ��3� 3��3� 0 PRESSURE GROUT <br /> 0*Other +++k/// i 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 /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: flSTEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTA DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE�usH POIN (GP r CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 1,W11S'OIL BORING 0 HAND AUG17 GROUT SPECIFICATIONS <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 20 'Fe4f 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 rdinanc Rules and Regulations, and all applicable California State Laws. <br /> c • <br /> Signed - Title/Company Rov ooGG L. C <br /> Print Nam L,S A \1C�Z Date Jc,A Lu \O k2C�Oto <br /> Q DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued 00,1_06, A(Pa 6 OW <br /> Grout Inspection By ate Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> le oe <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 />