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an Joaquin County <br /> Environmental Health Department <br /> SITE <br /> r 304 East Weber Avenue, 3rd Floor, Stockton, CA 95&cL LI �/fL� TIGATION <br /> (209)468-3449 Fax: (209) 468-3433 Web: www.sjgov. UNIT IV <br /> Well Permit Application <br /> ...._. .r•-� DEC 2 0 X006 <br /> NON-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 desc rtt�S'diittioN�Sa !in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environm <br /> S Owe— ��A/ t - � Zi q,Sj6// Assessors �� -/3 <br /> WELL Locati ross Stree City p ( F Parcel# <br /> ✓(4YPROPERTI- <br /> Owner. Address / /� 1;1✓t'1 Ade City Zip95.36� Phone# <br /> C 67 Contractor C�.� ��n y a 1)l� City, /'r- Fo✓r--Zip S�y� q Y <br /> / f�Ln. Address 95-C 4 �`j r1 Lic# Phone# <br /> Consultant/Sub Cntr//''(y r �� tt 11 Address 3S'/ i"'; SS c±_c City 1�'' Lic#/(tJj V! Phone# /�Ca s/-/'O a <br /> GIS Coordinates:X C, 3a 9 Y.Y -Il � 1 77J,Township S Range 49 E Section / <br /> WORK TO BE PERFORMED: <br /> I�NEW WELL/BORING (CPT,GEOPROBE,HYDROPU NCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> J� 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> LL# W- 0 PRESSURE GROUT <br /> Other GROUT SPECIFICATIONS <br /> COMMENTS: F11 F fffl <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING OLLOW STEM DIA.OF BOREHOLE_0 Li 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION IR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE LIED: 'OL�UGERS 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 fL <br /> 0 OTHER: 0 OTHER APPROX. BORING DEPTH Lj t 7 6OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED �l1 J /` (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 prep ed this application and that the work will be done in accordance with San Joaquin <br /> Cou 7inces, les lations,and all applicable CaliforniaState Laws. _ <br /> Signe Title/Company <br /> rv' E'er;f S e• �`�� Cr f �� <br /> -1 v/ <br /> 0 <br /> Print Name 1 �`�/t �_ � �- Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: R' - 0 , , I VC . <br /> WORK PLAN DATED: Y O <br /> Application Accepted By i d rinw, Date Issued anudrt, %7 07 —Areal + / <br /> Grout Inspection BDate 1 O Final Inspection By ft:�Acp-- Date I2 p_�r= <br /> Destruction Inspection By Date r r <br /> COMMENTS/CONDITIONS: Yl S is )I a L <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> *2961 Sq S9 sit# 60 <br /> 94 1 47 <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EIRD 29-02-001 <br /> 6/22/04 <br />