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_ v ILE COPY <br /> WEL�PERMIT APPLICATION =' <br /> SAN JOAQUIN COUNTY ;O^ �� GATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT ik 0��3, UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 952 ,'S <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin Count 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 ) Assessors <br /> t <br /> T ` { Cross Street City�r:07c '��_0"Zip Parcel# (57 I bv� 67 <br /> PROPERTY Owner TCk. til t- � Address <br /> Q� T x11 <br /> Cit4S 4+ Zipj' 03�hone# <br /> C-57 Contracto Address �7 Cit�Wip ic#?17SI�Phone t11� �fl� —11( <br /> Consultant/Sub Cnt �� �. �t o.6. <br /> �iat1YO�VLtet� ddress tt r City�DOYi��Lic# G Phone q( —2.( p <br /> GIS Coordinates:X Y Township Range_ 1y Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORI G <br /> )WELL# I -��4 1 0 OVERBORE. DIAMETER <br /> a PRESSURE GROUT <br /> 0*OtherGROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> $'MONITORING HOLLOW STEM DIA.OF BOREHOLE__V 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 914a 40 TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL �C� �Q 6 <br /> �"t©fREMIE TYPE TO BE USED: 0 AUGERS HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED:XYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS GBrue.Vnb <br /> 0 OTHER: 0 OTHER APPROX. BORING DEPTH Itl�O'3 l00 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED_ Ido (if YES,list specifications in comment section) <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 O nances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company y f �I <br /> Print Name �� Date 1O I 0 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: • W'a" S"y ew <br /> WORK PLAN DATED: -LZ-off <br /> Application Accepted By Date Issued Area .0 <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 /> L l 2-3 G tti ,t S R# <br /> p 53 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc�' 9/30/02 <br />