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PQ�IN�, San Joaquin County Oleo n <br /> ;z•` �`-�� '���:°_�tip, Environmental Health Department a�51�zE <br /> s �{ 600 E. Main Street. Stockton,CA 95202-3029 *IGA'I�fQ , <br /> (209) 468-3449 Fax: (209)468-3433 Web: NN�v��.sjgov.org/ehd �D� <br /> 8 <br /> Well Permit Application 14 <br /> .,-"-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 Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location OW MAQiA l)avjPkjn � Cross Street oD kYtr 1 Pty City VAan e-cal Zip 9533U Parcel#xAA-DSZ3-IS- <br /> PROPERTY <br /> Owner RiChnrd IownSertA AddressDIa3R_&L"Hjghu Po ct City (Z�ipof\ Zip 906 Q Phone# <br /> C-57 Contractor pAWtyjrj CSnF.nursn o eG 4r Address lhdiil Read City UT,,0Ltpfj Zipctsals Lic#UJ02 - Phone#�o9-Ut1�-leb�g <br /> Consultant/Sub Cntr 1)dy nr,4rvnC-nit,mnmenan P,lnc Address 1;-t 31ridw ockc( City Skwk.+ n Lic#6y aa-i Phone# coq- �1u 1 Ic�lo <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ,&NEW WELL/ BORING (CPT.GEOPROBE.HYDROPUNCH.HAND-AUGER,OTHER') a DESTRUCTION (choose type below) <br /> SOIL BORING# 131. 113P. ,R4 a OVER-BORE. DIAMETER <br /> a WELL# a PRESSURE GROUT <br /> a'Other GROUT SPECIFICATIONS <br /> COMMENTS: - <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING a HOLLOW STEM DIA.OF BOREHOLE 1.2,�! 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 a OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL D' TREMIE TYPE TO BE USED: GAUGERS a HOSE <br /> a AIR SPARGE/OZONE 7WPUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes J'No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> JCSOILBORING aHAND AUGER GROUT SPECIFICATIONS=/� 'PO,-Ro,,nCj NPC0 00WE"i <br /> a OTHER: a OTHER APPROX.BORING DEPTH D) a BOLTED TRAFFIC BOX or a 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 /> I hereby certify4hat I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Orc les gulationsf all applicable California State Laws.llfi <br /> Signed x. ZTitle/CompanyUice 1�aasder�� RdyGY�cPd GeoFnyiYWfnerAoD (nc <br /> Print Name 12 y�LA Date—Date-0. <br /> EPARTMME_NST/ USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: - <br /> WORK PLAN DATED: <br /> Application Accepted By /r �• Date Issued a' l� Area � y� <br /> Grout Inspection By k/1.�Mnne ave Date Final Inspection By Date <br /> Destruction Inspection By Dat <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 /> SR# S3 y S(� <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001web <br /> 6/22/04 <br />