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TILE COPY <br /> a <br /> MUM" San Joaquin County <br /> Environmental Health Department AP Slit <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 III+rGosON <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd ENVIRONMOIR <br /> T�) TH <br /> PE <br /> Well Permit Application F. <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 Titl ,CChhaapter 9-1115.3 an the Standards of San oaquin County Environmental Health Department. <br /> �LO�W' y f Zip 95Pcf Parcel#Assessors <br /> 20.9-27 O-US <br /> WELL Location oss Street W� Cit Tr-'A <br /> PROPERTY // l <br /> Owner C�tfr.<��S l�eL�l�n'zK ddress Zo/ MrsSt�� B(�p/ City`--F,--t-,s ,zip `�Y I- Phone* <br /> �y�� �97y_ `/�Dc, <br /> 11 l <br /> C-57 Contractor �aSG�dep �r°�lJ"� Address363z O��G (trC'P R a_cG_ <br /> City C� J,�g Zip S9 7Y7 Lic#�i��t�Phone# (}t6) 6Z�-(16� <br /> & <br /> SLie#Consultant/Sub Cntr Address 2/� Cit dv <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> a NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) a DESTRUCTION (choose type below) <br /> 'SOIL BORING# 2 9 Ba OVER-BORE. DIAMETER <br /> a WELL# 0 PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE 6 a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC 0 OTHER: A114 <br /> a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 2S TREMIE TYPE TO BE USED: GAUGERS _2-1-IOSE <br /> 0 AIR SPARGE/OZONE <br /> PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING �BAND AUGER GROUT SPECIFICATIONS +yea j «'-­-t-- <br /> a OTHER: a OTHER APPROX.BORING DEPTH 2 S a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED 1.44 _(it 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 Or es, Rule and Regulations, and all applicable California State/�L,�a�ws. p <br /> Signed x Title/Company (-�fl�tysf SA'/ <br /> Print Name Liu Date �66 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ON de, <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued - .7 Area <br /> Grout Inspection By ate 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 /> I �!f /�W�T. y- I C- 7 t,- <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc <br /> 131413 29-02-001 <br /> 6/22/04 <br />