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FILE COPY <br /> u 60%31 San Joaquin County <br /> GMTyEnvironmental Health De artmentSITE <br /> D <br /> a <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 L5 GjEOIf,�N <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd IV <br /> • L R `" Well Permit Application AOR 12 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENT HEALT� <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install the work described. This a� 0 pmpfance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin ounty Environmental Health Departm nf.��� <br /> 6 nogg THnRA'1w1 /.-iD Assessors <br /> WELLLocation ly7l1 I �� INaRn'fo.�1n CrossStreetcAgag-- AvCCity LDS/ Zip 9S7YZParcel# 055-15 '2ls <br /> PROPERTY n i <br /> Owner A:tu�I{N]—iAddress�0. Uov 1QJ& City TfAc.t.--Zip95y_7f Phone*3o 9532-- 780" <br /> RgSenA,y7 snarl FnsT s+. cIA/nlc p9sTilt - --- yZy <br /> C-57 Contractor 7LjJ Arno troMr. Address 22 o N. O dJ/ D�Ai+r�i Lidr$O Phone# O 6b <br /> Consultant/Sub Cntr A G Address g37 SJ�A„✓rf O. CityS7ocK^rn.. Lic# �Sti Zz7 Phone# OQ'1Y(D 0® b <br /> GIS Coordinates:X ,Y _ ,Township 30 Range d CF Section_,l <br /> WORK TO BE PERFORMED: <br /> ANEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> n SOIL BORING# u OVER-BORE. DIAMETER <br /> WELL# Mw-/3 r Mck) 1 Mvi-15 a PRESSURE GROUT <br /> Other GROUT SPECIFICATIONS <br /> Re flf�.xeuy <br /> COMMENTS: WORK PAN i4aeo dvn-� - !)FcaM.rEor Zoog yd wv�r OCo✓ A22eM�r^�T31 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �� <br /> MONITORING n HOLLOW STEM DIA.OF BOREHOLE" O MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA:�•Z <br /> TRACTION D AIR HAMMER/DRIVEN CASING THICKNESS stbae/e yr TYPE OF CASING: O STEEL Q PVC OTHER: IQ X F 74 17,! <br /> a VAPOR O MUD ROTARY DEPTH OF GROUT SEAL // r TREMIE TYPE TO BE USED: GAUGERS OSE <br /> p AIR SPARGE/OZONE p PUSH POINT(GP or CPl)GROUT SEAL PUMPED: p Yes )If No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> a SOIL BORING 13 HAND AUGER GROUT SPECIFICATIONS F CIA r <br /> OTHER Sen I[ BORING D BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> p OTHER: ` <br /> 15'Tee 1 CONDUCTSgRfC� ING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: \O A DM I dor GRS"Aa fro <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 California State Laws. <br /> Signed x U4U Title/Compan Acl •!&-T /4 M' G <br /> Print Name Tim O 7, )g J C '/F/�9/ Date <br /> DEPARTMENT USE ONLY ,,,, <br /> SITE MAP IN UNIT IV FILE, ADDRESS: �Y --- - " p <br /> WORK PLAN DATED: Z Cl <br /> Application Accepted By Dale Issued 7 -05 Area 0 6 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> O g �� SR# ©� ) 8 <br /> C-57� WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 622/04 <br />