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0San Joaquin County 40 <br /> Environmental Health DepartmenSITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95 ��� V�nE�TIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/chd UNIT IV <br /> Well Permit Application MAY 1 9 2005 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE islib UnONM'ENT HEALTH <br /> d. R <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work describ W1�i@ D jk4WA@ade in compliance with San <br /> Joaquin County Development Title,Chapter 9-1111155..3 and the Standards of San Joaquin County Environmental Health Department. <br /> 746}S. � p��tl . Cr sStreet�W <br /> Assess <br /> WELL LocationCltyS40L'' zip9SZls Parcel# $1- IO-ou( <br /> �.y ¢ qs X Ae l <br /> PROPER�I' t`i LV1,�rannce.c-I.cr� I c-t-T-' �-+-- <br /> Owner t� pr° S I. <br /> Addres,� Cil Zip Phonel ll =fteaft <br /> C-57 ContractorIC.�J Address0 N-Fk- 554- CihQD141a--U Zip % Lic#_r Z33y Phone#(S3 0)�6k-ZL{ <br /> Consultant/ ub Cntrl_US C.O- Address 1360 City Lic# Phone#(7S 35 -2Hoc-) <br /> Ce/(V7:5 256-6165 <br /> GIS Coordinates:X ,Y ,Township 15 Range Section <br /> WORK TO BE PERFORMED: <br /> ) NEW WELL/ BORINGCPT, PROB HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> „SOIL BORING# I�—Z D OVER-BORE. DIAMETER <br /> 0 WELL# 0 FICATIONPRESSURE GROUT <br /> O'Other 1 1 C) OU l P�""r S. _11c+1- <br /> k S IU1 _ <br /> COMMENTS: SO VV 6 G.W. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS J <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLEZ-A a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:JJ <br /> n EXTRACTION n AIR HAMMER/DRIVEN CASING THICKNESS 0�TYPE OF CASING: n STEEL 0 PVC 0 OTHER:NO <br /> 0 VAPOR n MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: p AUGERS p HOSE <br /> 0 AIR SPARGE1 OZONE*PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: NJAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING O HAND AUGER GROUT SPECIFICATIONS JJ CCe-'Au <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH Z-5 I4. I ISA 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NO (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 rdina Regula , n nd all applicable California State La//ws.II <br /> Signetl x Title/Company lYttXO <br /> Pdnt Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: F -[ -6 :2 S • —IS-C-C UL <br /> WORK PLAN DATED:_ DiL,-L <br /> Application Accepted By �N ' cB�LC� Date Issued .�lo'Lqd Area <br /> Grout Inspection By n4 ate Zl, D Final Inspection By Date <br /> Destruction Inspection ByDate <br /> COMMENTS Irn rnnnuc- I 1„ O.r itI nn Z+ 9T r'yr l i�z'1'P� SwrnP leS L'!i 11P <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT SERVICE REQUEST# INVOICE <br /> lq <br /> 111093 s _AV SR# �Fa <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 />