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.�p'qu!".. c�_n Joaquin County <br /> EnvirGftental Health Department /- <br /> SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 .// NATION <br /> ' (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd L'= iJI_T IV <br /> 0. Well Permit Application lic SEP i 5 A <br /> � <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENV(��D 1, '„l ALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This app j r�r¢ Ny�qb �'iiAnce with Sanoa�in County3Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Healthy 1144MM ivt. ES <br /> Wa �/ / Q Assessors ,/ -/ <br /> ELL Location 064 �l 7 Cross Street City Zip / Parcel# -0 <br /> OwneERTY LeS —Address—370-S-7o-5 ��"& n ity - Y/ Zipq-'C�2' Phone# y7( 4M <br /> C-57 ContractorOhi?e City �Z�ip����`tic '�'"Phone`#/%�d�3� —ilk <br /> Consultant/Sub Cntr �7� Address �� sk'a' � City SYc W-kic# Phone# J 07 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# ORIGINAL <br /> 0 PRESSURE GROUT <br /> 0"Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> PE OF WELL INSTALLATION TYPE CONSTRUCTION SP CIFICATIONS n <br /> IkONITORING ]41OLLOW STEM DIA.OF BOREHOLE/ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 10 TYPE OF CASING: 0 STEELPVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Fes" TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes XNo (NOTE: MA�jCIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS T <br /> 0 OTHER:_0 OTHER APPROX. BORING DEPTH_� OOLTED TRAFFIC BOX or^ft(STOVE PIPE <br /> C <br /> / ) CONDUCTOR CASING PROPOSED (if YES,list specifications iomment section) <br /> M <br /> COMMENTS: � L✓/S -A 1(' �h <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 Ordinances, Rules and Regulations, and all applicable CaliforniaState Laws./ <br /> Signed x �i� - ) �X - Title/Company T7 6-2C— <br /> Print Name ��f f In G( r.k­ u LlQ Date 1 1� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: ? 3?— 5. H w -,/ 99 <br /> WORK PLAN DATED: Awa u3t 30, zo of <br /> Application Accepted By Date Issued - - A Area 145-1 <br /> Grout Inspection By C 4 "' to I6 -,,d -0 S- Final Inspection Date /Q// -O i <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: S Y VJ 2. 16 101" <br /> cy <br /> ACCOUNTING ONLY: AID# FAC# ' <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> qp '7 11n w 8 q z2 �zs �- q�s_v SR# 5 � do 3 47 <br /> C-57_ WC V -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />