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� • €-°*` San Joaquin County c)j <br /> Environmental Health Department <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 FEBj M lqATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd Eh'VIRUNIT IV <br /> 's3 Well Permit Application <br /> PERM <br /> Ijs ij <br /> ICES <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 /> nn <br /> Joaquin County Development T'tle,C�a ter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. 1, rr� -CR-y�y <br /> vJ-GrrL� S, Ax- Assessors 1 <br /> WELL Location a 4-o- Vis Cross Street City ��/Zip Pa^rrcel# <br /> PROPER <br /> Owner �Y If S�oc,K 1 Address Z&Z N&LN Or 4X, <br /> City S4 4 Zip%Vo Phone# <br /> . <br /> C-57 Contractor Fi5r-k-:A j,rvt" Address 31111 .41ui g Pl&t@ City�ip Lic#683365Phone# <br /> I$1S F,,r,pp��•K V.)44C•rcic c�` ,r <br /> Consultant/Sub Cntr Co0jer Address <,I, Z City �71v<.+►tarl Lic# Phone# 2-CA-Z34-c>519 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> )(NEW WELL/ BORING (CPT,6PROBE HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# PRESSURE GROUT <br /> B•Oth/e�r �N[� p�" OrA► ! G,,SOb-pu4j pu�u kAjA&t y.,-IZ GROUT SPECIFICATIONS <br /> COMMENTS: PreoosA uJerK A su,� ',A. Pkcrs. Y E"obw��.l S-k Assam 0bry- Pb A IJAU R6 :7,ZoaS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE I• a []MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE R'PUSH POINT GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and egulations,and all applicable California State Laws. / <br /> Signed x �'�""� Title/Company 56r 06 - 4 1 c <br /> Print Name VWiV- pru4-&-S —Date-2-15 _175 <br /> DEPARTMENT USE ONLY / ' <br /> SITE MAP IN UNIT IV FILE,ADD ES$: — .S baur4 <br /> WORK PLAN DATED: -2 ` `� <br /> Application Accepted By � Date Issued <br /> Off/ /0 / d J Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> P% 1 1 3 a�# � 1 2//�75s SR# yea <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 />