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fan Joaquin County � <br /> �Lrr,�L�� a <br /> Environmental Health Department AUG jSIT <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIG5AN <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/ehd EN1IR0,1 <br /> MiT WA LTH <br /> Well Permit Application PERMIT/Sm/,IC€2 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install 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 /> WELL Location 'V/4 S. 4V a--, f ee> Cross Street Wel`-�>-,f ✓�� Assessors <br /> City �f e� Zip 9c-7'37 Parcel#;?/-I-TL3G -?-T <br /> PROPERTY <br /> Owner k<, .I,'�- dL"o-1- Address if-Z CLA�City Zip Cf5 &i-Phone#CZags 23q-797 2S <br /> C-57 Contractor r' rc4 5 t7e�-:a 0 -e- City Yq 'Z Lic#&M3`S Phone#tZ­q <br /> Consultant/Sub Cntr C ted.- Eur J�4i r�� Address_17 39 44 2✓ City l�e�e� Lic# Phone#(7-q)'S&-& <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED. <br /> (NEW WELL/BORING CPT,GEOPROBE,HY CH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE G <br /> 0*Other GROUT SPECIF I <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CON§:6 T�I SPECIFICATIONS <br /> MONITORING a HOLLOW STEM DIA.OF B LE2 � 0 MULTIPLE CASINGS MULTI-LEV L CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THI ESS TYPE OF CASING: 0 STEEL 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH SEAL TREMIE TYPE TO BE USED: UGERS 0 HOSE Z <br /> 0 AIR SPARGE/OZONE XhUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FRDEPTH IS 30') <br /> JrSOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS U:r� r <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 3- 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE F <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) t/ <br /> COMMENTS: Css�-��X' - %+z u ;/,4 ?�,rT Ger i 'I <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 Ordinances, Rules and Regulations,and all applicable California State Laws. c <br /> Signed x <br /> Title/CompanyVeZc>o �'r« r%��Ls <br /> Print Name L,(:fe Date 7 l m 106 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: l S'. fVlai► S � �1�lau� -c�. <br /> WORK PLAN DATED: <br /> F! <br /> Application Accepted By ✓ Date Issued �L XkArea <br /> Grout Inspection By t Date Final Inspection By Date 5- f� <br /> Destruction Inspection By <br /> Di3te ) <br /> COMMENTS/CONDITIONS: C i - <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> 3 �� to � I`a/CL. sR# <br /> � ��� �,I �. <br /> C-;7 WC WAIVER_ C-57 Letter of Authorization to sign permit_Encroachmen ��''^^�� <br /> EHD 29-02-001 S �� C vyt l.,J <br /> 6/22/04 <br />