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°Qc, SAN JOAQUIN COUNTY �� SITE <br /> n y� EN , &ONMENTAL HEALTH DEPARTN �. 4TTIGATION <br /> d 304 East Weber Avenue, 3 d Floor, Stockton, CA 95202-2i ILS II// <br /> (209) 468-3449 • Fax: (209) 468-3433• Web: www.co.sanjoaquin.ca.us/ehd V Iv <br /> >z `r 5 ?005 <br /> WELL PERMIT APPLICATION FORM ENVIhUMEN% �T � e`" <br /> Application is hereby made to San Joaquin CoIALM <br /> unty for <br /> permit constra t and/or IT REstall the worS 1 YEAR kdescr <br /> scriOM DATE bed. This aplpli SSUER�li�h'i5 Mddwrr::r�mpliance with San <br /> Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELLLocation2OeC AX00040 "r %rCross street L Aud d City S1BC .e Tom Zip Parcel# /z// // zo3 <br /> PROPERTY Owner SF.Z 7 ,55601itp� Address l.3$W PNeASt'M Jed" C.City .y-7y�,ICya,� ZpqSAeAW -Phone# 933 P1�7S <br /> C-57 Contractor GJUO �jWAf@t�b Address Poo . RD )( _ ?.? 4 Cityl2lo WS7AZipy 57/ Lic#7/0079Phone# 70737) /5f� <br /> Consultant / Sub Cntr Address 110 40CF&P, AVVECityitf9d.& r Lic# Phone# S7J ' Z ZZ/ <br /> GIS Coordinates: X , Y , Township Range Section <br /> WORK TO BE PERFORMED: <br /> JeNEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) U DESTRUCTION (choose type below) <br /> 0 SOIL BORING # 0 OVER-BORE — DIAMETER <br /> P0 VjC€LL # 0 PRESSURE GROUT <br /> Other: EPe. AC4w Ew fbL MWw / 1 Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INST/AL TII A ON TYPE CONSTRUCTION SPECIFICATIONS <br /> KONITORING OLLOW STEM DIA. OF BOREHOLE 46 "MULTIPLE CASINGS? 0 YES goN15' WELL ASING DIA: A <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SCh/ qO TYPE OF CASING: 0 STEEL 0 PVC OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL e> Sa ' TREMIE TYPE TO BE USED: 0 UGERS 0 HOSE <br /> [IAIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: gyre 0 No (NOTE: MAXIMUM FREE-F L DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: ❑ OTHER APPROX, BORING DEPTH 601OX 6S 0 BOLTED TRAFFIC BO STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? " C ( If YES, list specifications h re) <br /> *COMMENTS: m <br /> NOTE : OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMIToS1 <br /> CALL THE UNIT N INSPECTOR 48 WORKING HOURS IN ADVANCE FOR Laccor <br /> INSPECTIO . ��J <br /> hereby certify that I have prepared this application and that the work will be done with San JoaquinCounty Ordinances, Rules an Re lotions, and all applicable California State LaSignedx -kms Title/Company 6AC �0&"cOeA 7etS <br /> Print Name .tJEdt to <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : 6ko ss 5 wow . S t <br /> WORK PLAN DATED : 3 / 5 a zl <br /> Application Accepted By Date ssued t{ S OS Area <br /> �� Z l <br /> Grout Inspection By (A�,r V , Date Final Inspe on <br /> By Dater/ <br /> Destruction Inspection By Dat., <br /> COMMENTS / CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEEINFO AMOUNTREMITTED CHECK # RECD BY DATE PERMIT / SERVICEE REQUEST # INVOICE <br /> 35O ( 21 , 00 to ( ( /, f `l SoS SR# � 1 <br /> C-57_ WC.-WAIVER. C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br /> HIRE) 29-02-001 WELL PERMIT SITE <br /> 8/272003 <br />