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RED <br /> WELL _ ERMIT APPLICATION FL.M %Ajj <br /> SAN JOAQUIN COUNTY GAIT T N <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) 4J1MIT1TI <br /> {p�l 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> . (209) 468-3449 o ""''�o <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED � <br /> Application is hereby made to San Joaquin County for a permit to construct andlor mstall 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 /> r r fr Assessors 'Y� <br /> WELL Location Q �rO_r�a Cross Street F. !��''f CitYStc�K�c r Zip�$`TSZaS Parcel# /`��' <br /> PROPERTY <br /> Owne Address:�jS Z3 � V,r na-�n C� �r54 , Z'p :5 z- �Phone# /v LA <br /> i <br /> C-57 Contracto,_C d- q <br /> 4 ,.�c.. Address(:�SC ! C�ty/"t .wtZ Zip`�YS L�c#� ` Phone#�z 5'3I3'X00 <br /> Consultant/Sub Cntr �'pn,3�,.,.�___ Addresses- �¢rlt,-G s'f City �LiG 627_4Phone# �o -si35-y8� <br /> GIS Coordinates X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED <br /> p NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION (choose type below) <br /> 51�SOIL BORING# SI3-Z a OVER-BORE DIAMETER <br /> []WELL# lJ PRESSURE GROUT <br /> Q*Other GROUT SPECIFICATIONS <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> []MONITORING 1]HOLLOW STEM DIA OF BOREHOLE3 q a MULTIPLE CASINGS []MULTI-LEVEL WELL CASING DIA <br /> Q EXTRACTION [I AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING 1]STEEL []PVC []OTHER <br /> WOPR a MUD ROTARY DEPTH OF GROUT SEAL 1 0 TREMIE TYPE TO BE USED DAUGERS HOSE <br /> SARGE!OZONE.-B:PUSH POINT(GP or CPT)GROUT SEAL PUMPED `gYes Q No (NOTE: MAXIMUM1 FREE-FALL DEPTH IS 30') <br /> ;5SOIL BORING a HAND AUGER GROUT SPECIFICATIONS T6 -4 (4'k �S`�� ��T �. <br /> []OTHER n OTHER APPROX BORING DEPTH 15a / _0 BOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS Com' o r S1'S-Z f- TM,a cc L a <br /> NOTE: OFFSITE B RINGS 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 Ordinances, Rules and Regulations, and all applicable California State Laws n� <br /> Signed x ©■— - Title/Company �s�-, <br /> Pnnt Name �� Cs+-�rn� ^ ' _ _Dater) ZSs o v <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 7— E. ruSte" <br /> WORK PLAN DATED: S -0A <br /> Application Accepted By. Date Issued 4 l6 "6 Area et/ <br /> Grout Inspection ByDate Final Inspection By Date <br /> Destruction inspection By Date <br /> COMMENTS I CONDITIONS <br /> ACCOUNTING ONLY AID# FAC# <br /> ODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMrr!SERVICE REQUEST# INVOICE <br /> 350 65 l os 6-1—off- SR# 00"73 <br /> 9/30/02 <br /> C-57 WC -WAIVER C-57 Getter of Authorization to sign permit Encroachment doc <br />