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• • FILE COPY <br /> San Joaquin Coanty <br /> Environmental Health Department SITE <br /> DATION <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 9520 ������ <br /> (209)468-3449 Fax: (209)468-3433 Web: vAm.sjgov.c IT IV <br /> �tira� <br /> Well Permit Application OG - 2005 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSU <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. �}�, rCBtl i8E4]ij Kompliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmen Igi9� %sessors <br /> WELL Location <br /> e. il,- &!- ,� Cross Street '40 t I w�` ,ae Zip '16�j0 Parcel# 213^2l0 L <br /> PROPEr�x� L,",ro Zi ZCS330 Phone# <br /> Owner 1'�v� tro�nv�s Address�3 W. S�e�"�� City ( P <br /> Owner <br /> y ti Dn�l,^s _Address Q� g OY 41� City(sley,�,� Zip U641 Lic#.I20ttAPhone# (-416)}'}� <br /> Consultant/Sub Cntr�"`aev ("-"' Address 2$'60 t'- -CrFw City T��Y Lic# Phone# (ZZR V8 0^00 <br /> GIS Coordinates:X <br /> y.,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ](NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 OESUDIAMETER_ <br /> N METER(choose type below) <br /> R <br /> SOIL BORING# r D PRESSURE GROUT <br /> ELL# GROUT SPECIFICATIONS <br /> - <br /> a*Other <br /> COMMENTS: <br /> TYPE OF WELL INS LLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> rl <br /> I(MONITORING HOLLOW STEM DIA.OF BOREHOLE in 0 MULTIPLE CASINGS D MULTI-LEVEL)WELL CASING DIA: <br /> D EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 1l,PVC a OTHER: <br /> TREMIE TYPE TO BE U21cl': D AUGERS D HOSE <br /> 0 VAPOR D MUD ROTARY DEPTH OF GROUT SEAL <br /> D AIR SPARGE/OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> D SOIL BORING D HAND AUGER GROUT SPECIFICATIONS BOLTED TRAFFIC BOX or D STOVE PIPE <br /> D OTHER._O OTHER APPROX.BORING DEPTH D <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 certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County O ances, les and/Regulations, and all applicable California State <br /> Signed xi�- �yy�L Title/Company 15 6ilro <br /> ,��r,,� f^J/GK.Ki7T Date B�Uf� <br /> Print Name <br /> DEPARTMENT USE ONLY \D Z(�j,lo S W <br /> SITE MAP IN UNIT IV FILE,ADDRESS: n- 766 t/a <br /> WORK PLAN DATED: <br /> V� / �5 <br /> Application Accepted By r Date Issued Area <br /> Grout Inspection By <br /> Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTI*ONLY: AID# FAC#PE CODESAMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> O � SR#C-57_ = IVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />