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an Joaquin County <br /> :: ... Environmental Health Department aSITE <br /> 304 East Weber Avenue. 3rd Floor, Stockton. CA 9202 r IGATION <br /> (209)468-3449 Fax: (209) 468-3433 Web: www.sjgoN,.org/ehd <br /> Well Permit Application <br /> UNIT IV <br /> OEC 2 0 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED/V1��r1 � . 'ta= <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. 1//& /Z-2/ U G <br /> p t17 C010Assessors t� <br /> WELL Location F �" "/ In"/ /�QCross Street� J'��� ���ity �l Zip .S-3 66 Parcel# �7 <br /> PROPER / C� ,r p �y <br /> Owner - ✓ Address ' sf A M C- AL'eCity � Zip�3(06Phone# - �� �-5r1/ -�) 0 <br /> p 3�ss L� 2u <br /> C�i7Contractor leS� A��1��� Address yuN-4 City n O Zip 95_7y aLic# gr ` one#9/6` 6SF��y <br /> Consultant/Sub CntrL� E iJ )Z Address 3 s� /2u PSS C City� _Lic#34q-5 <br /> p +5Phone# <br /> GIS Coordinates:X �L �OJ� 1 Y �O Township S Range 0 C Section O <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPU NCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type belo ) <br /> SOIL BORING OVER-BORE. DIAMETER <br /> WELL# 43 ��(�;-a/m-a����`� 3b�/� Q PRESSURE GROUT <br /> 0*Other GROUIM17IONEL <br /> COMMENTS: F <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFI ATIONS l( <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE `' �IULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: d�y <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS CI+ 4D Y PE OF CASING: 0 STEEL XPVC 0 OTHER: <br /> USED:0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE ED: ' AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH '10 f DOGE BOLTED TRAFFIC 9M*or 0 STOVE PIPE <br /> 1 COYD,UCTOR CASINNG`PROPeOSED (if YES,list specifications in comment section) <br /> COMMENTS: Cz",duCk(, '" t ` 4 C( fw IIW-/.b �A <br /> 'Cl 11 (13 A ck�k L C-IS <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 S n Joaquin <br /> Coun s, Ru and Ions, and all applicable California tate Laws <br /> Signed x - Title/Company ( �_C-/ �c� J� Fo� <br /> Print Name l -n IT �� Date �� �C% a <br /> DEPARTMENT USE ONLY I / � 1 <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 12,rht4-U/a y 4-r GaodW i n In dn4-(nn.o1DAu Rel- (: h ()FR„oan <br /> WORK PLAN DATED: A u gy s 3 1 )_00,6," <br /> l r <br /> Application Accepted B I l ! e P Date Issued ifa(- 6 Area <br /> Grout Inspection By=&2� 2W_ Date 7 Final Inspection By <br /> Destruction Inspection By —�^ D e 7 <br /> COMMENTS/CONDITIONS: 191A I D hA W-2 - 3 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> j,30* e'2 g9+_ �;9�5_ SR# 0 224 <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 /> RO 060 /7S S' <br />