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r ^ <br /> San Joaquin County FILE COPY <br /> Environmental Health Department P w 2 ; � � II5IT€ <br /> ' <br /> 4 j 304 East Weber Avenue , 3, :1 Floor, Stockton, CA 95202 �l �L (C-I{TI 'GXTI0N <br /> ( ) 1 1 www. v. <br /> 209 468-3449 Fax: (2098-3433 Web: sjgoatg/ebd +A7I51} A IV <br /> WAV <br /> t./ �r ` lJlT <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED _ (VVIRONAAtPJ1 I-ZEAL I H <br /> IDFRMI i //Sn(.2e , rrG <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made i SmpYrahce with San <br /> Joaquin County Development Title Chapter 9-1115.3 and the Standards of Salt Joaquin County Environmental Health Department. <br /> �E I l Assessors �y <br /> WELL Location 1 30 c0 t [l:"YiL:� -�TvT Cross Street ST• City U �CS - r- Zip I � C'�iiC`Parcel# 13912000Z <br /> . 'PROPERTf city lnAddress C5 1\1C � ) Zip-1 r^- <br /> Phone# <br /> C-57 Contractor Address City Zip Phone# 5 7 <br /> Consultant / Sub Cnlr ;t s�1r) i., I •.�-? t r-' Address ~`c u •^� I Cit - • �Cr'iLic# �U b Phone* 1 �� r X55 ! (J <br /> GIS Coordinates: X Y , Township Range Section <br /> WORK TO BE PERFORMED: - <br /> D NEW WELL I BORING ,^ LGEOPROBF, HYDROP .H,HAND-AUGER, OTHER*) D DESTRUCTION (choose type below) <br /> SOIL BORING # ` ':,; C" h'•"<. T6 e ''..0=C' 0OVER-BORE. DIAMETER <br /> • <br /> WELL <br /> U LQ , L ,PRESSURE GROUT <br /> O 'Other VIA-$ • 0 GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLES 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS T YP i OF CASING: D STEEL 0 PVC D OTHER: <br /> 0 VAPOR D MUD ROTARY DEPTH OF GROUT SEAL G0 TREMIE TYPE TO BE USED: flAUGERS 0 HOSE <br /> 0 AIR SPARGE/ OZONE XPUSH POINT (GP or CPT) GROUT SEAL PUMPED: Yes 0 No ( NOTE: MAXIMUM FREE-FALL DEPTH IS 307 ) <br /> -SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: D OTHER APPROX. BORING DEPTH 7p BOLTED TRAFFIC BOX or D 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[I/1�as, u�lee and /e ulations, and all applicable California State Laws. <br /> Signedx /[mac )G✓ -�Y ir/JL Title/Company IY-�a j, ``lT?-fl r i DAlo Lnc—s . <br /> Print Name ,Y ceyf f / f x c✓I Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE , ADDRESS : 1 3 C Nbr+F H u n- i- Plr S-t-ree+ <br /> WORK PLAN DATED : No Ve m Lo r 4 2 D O4 <br /> � / r <br /> Application Accepted By V D q � � Date Issued d )649 y,, S . 2d Area 1459 <br /> Grout Inspection By V 1fk l rl lr, rnd4C4b" Date 11 1 rb Final Inspection By pate 1) 12 -0 � <br /> Destruction Inspection By Date / <br /> COMMENTS I CONDITIONS: Ad PV b �� � rive, r d� 6 <br /> %`TGCC <br /> ACCOUNTING ONLY: AID# rq�p <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> 3501 89400917 . 00 ISR40040300 <br /> C-57 WC.-WAIVER— C-57 Letter of Authorization to sign permit_ Encroachment doc <br /> END 29-02-001 <br /> 6/22104 <br />