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FILE COPY <br /> San Joaquin County <br /> x Environmental Health Department <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 APR 2TI GATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd E ��T IV <br /> NVIRO. <br /> Well Permit Application PERM U <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I T/S�RVICES 17 <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 <br /> Title,,Chapter 9-1115.3 and Jh Standards off San Joaquin County Environmental Health Department. Z�_ 2 <br /> Asse <br /> WELL Location lia a� GV• -Wross Street 16tH"7�� City f aL zip �S3U`� Parcel#ssorc J <br /> PROPERTY 1P <br /> Owner DkA�y�'^der S"��' + AddressH_Z_Z z W• g`d('A RA. City IrA-f Zipgs `{ Phone# O <br /> C-57 Contractor CD Sc- � i�r �ll�� Address 3� 2 d"^� C i�C(e City Cv -bum Zip1RWLic#7175710 Phone# X16 422 - 1169 <br /> 37roo WA,4 <br /> Consultant/Sub Cntr > Z Address 5-"f r- 21 a City -04A cLic# 1i Phone# ()f6) d-7) <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> XNEW WELL/BORING ((PT,GEOPROBE,HYDROPUNCH,HAND-AI ICER,OTHER*) p DESTRUCTION (choose type below) <br /> ,'SOIL BORING#_ �n C 0 OVER-BORE. DIAMETER <br /> a WELL#_ ;� *y3 S�3 (�/� 0 PRESSURE GROUT <br /> 0*Other - _ / GROUT SPECIFICATIONS <br /> COMMENTS: _ S1 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE G t a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESSV'A TYPE OF CASING: a STEEL a PVC a OTHER: N�h' <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL Z S ' TREMIE TYPE TO BE USED: *AUGERS HOSE <br /> 0 AIR SPARGE/OZONE USH POINT(GP or CPT)GROUT SEAL PUMPED: U Yes o No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING HAND AUGER GROUT SPECIFICATIONS Nt fk C C"kt'j <br /> D OTHER:_0 OTHER APPROX.BORING DEPTH S �{ 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED N� V (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 Or in , Rules a Regulations, and all applicable California State Laws. ^ <br /> Signed GZ Title/Company6��Jt A�A'l/l_� <br /> Print Name 41,U 1qdV&&eDate /�1t' <br /> DEPAARTMENT USE ONLY /— Z?,/D <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 0 Yzl'lxe 4/ +/" &4"r I V <br /> WORK PLAN DATED: 'dS <br /> Application Accepted By Date Issued 5-19 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 /> Z2o I /6z�y16 -z6 SR# p pCleo <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_V"Encl-poeHlrent doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />