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• �0.�f FILE COPY <br /> o nt San Joaquin County n�� <br /> Environmental Health Department W <br /> s 304 East Weber Avenue,3rd Floor, Stockton, CA 9520211'1103110N(209)468-3449 Fax: (209)468-3433 Web:wwwsjgov.org/ehd AUG 1 7 20WIT IV <br /> ,Foa Well Permit Application ENVIRONMt.1gLT7 H <br /> E <br /> NON-REFUNDABLE PERMIT EXPIRES 7 YEAR FROM DATE ISSUED PERMIT/SRVICES <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 /> G� p��� I ��. �����t� Assessors <br /> WELL Location l� W Wllamin �O�t �Cross StreetGff4bj9R �tY Zip Z� Parcel#C�I���IO'773 <br /> owner LN //���� � LL la�lr, C�CnCI ZIpQ Pho-57 <br /> Owner ln� Ih LCrTIgV Address 1-r I� C I fry} <br /> C-57 Contractor- UYvt Addrels-�s�Z50 I/t/I_��'tY✓\�t'•Ci.yry,. ZiP9J�CS Lic# I �64S Phone#�)465-8}IZ <br /> Consultant/Sub CntrLF2 LeYIne, TIC�Q4ddrees 1q�0 W �Fttd�ityEA1EQ4VIUrEic# NA Phone# o 6S Z-4SOo <br /> �/�q_Range Section <br /> GIS Coordinates X�_.Y--N1-A—,Township � <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') O OE STER RU <br /> RE. DIAMETER_ <br /> (choose type below) <br /> 0 SOIL BORING# a PRESSURE GROUT <br /> SWELL# DP E' Tr' l+µ'� GROUT SPECIFICATIONS <br /> p <br /> *Other ` <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS !! u <br /> 0 MONITORING I HOLLOW STEM DIA.OF BOREHOLE I Z ()MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA:Y2� <br /> it EXTRACTION a AIR HAMMER/DRIVEN. CASING THICKNESS&--h. 90 TYPE OF CASING: a STEEL I PVC a OTHER: <br /> O VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALO-35-F-F TREMIE TYPE TO BE USED: I)AUGERS I HOSE <br /> g AIR SPARGE1 OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: I(Yes n No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> a SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> fl OTHER: a OTHER APPROX.BORING DEPTH C��'f Q BOLTED TRAFFIC BOX or STOVE PIPE <br /> " COND C'OR CA NG PROPOSED n6 (if YES,list specifications in comment section) <br /> COMMENTS: Aff,*-/ <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 Ord'na ce Rut and Regulations,and all applicable California State Laws. a / <br /> Signed xa fn Title/Company Y <br /> Print Name N^K t4A�f 1 Date 0 Z <br /> DEPARTM NT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: Z5. <br /> Date Issued Area <br /> Application Accepted By <br /> ! J�`� O� <br /> Date Final Inspection B to <br /> Grout Inspection By <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 I SERVICE RpEQUEST# INVOICE <br /> If-/ SR#& �9 Z <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 /> 1 �o <br />