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eSan Joaquin County • <br /> Environmental Health Department <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> wo <br /> ' U MP�IQI �/N����� <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED p\��M\�IS� <br /> Application is hereby made to San Joaquin County for a permit to construct and/or Install the work described. This application is made(h compliance with San <br /> Joaquin County Development Title,Chapter <br /> ff9��9-1115.3 and <br /> the Standards of SanJoaquinCounty Environmental Health Department. <br /> WELL Location /�/fJ/ �/�- �A&77/CY Cross Street-;-'/ ' Vt✓ Cit W- ZI c Assessors 02 <br /> y +hro(� p q 33o Parcel# 213-A90- <br /> PROPERTYT� O TR&sT <br /> Owner U Address W. SI-r�a�4 PA.City Lo.�t�r Zip95330 Phone# Z6 S,4:j 4-900 V( <br /> C-57 Contractor RGSenr n 11- 5onoz, Address7,10 N. E 54 61rft� Clty. v4 ianA Zip95-1Lic# 7. Phone# `J� �$�.�It <br /> Consultant/Sub Cntr I:t.l(260 -.Enc. sv Cily�Lic# Phone#Cjlc9) $3$-0614 <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CP VOPROBE,,YDROPUNCH HAND-AUGER,OTHER') Q D RUCTION (choose type below) <br /> a SOIL BORING# a ER-BORE. DIAMETER <br /> a WELL# RESSURE GROUT <br /> $*Other - ROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL IF 61117 Ilk <br /> STA ATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING OL W STEM DIA.OF BOREHOAll <br /> INGS p MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION Q A MMER/DRIVEN CASING THICKNOF CASING: 0 STEEL Q PVC Q OTHER: <br /> ()VAPOR a M TARY DEPTH OF GROTREMIE TYPE TO BE USED: O AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL asOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> H SOIL BORING a HAND AUGER GROUT S EIj ¢ <br /> a OTHER: 0 OTHER APPROX. (1 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> COND A (if YES,list specifications in comment section) <br /> COMMENTS: K- ti n YidIP a <br /> NOTE: OFFSITE BORINGS REQUIRE AC SS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS TICEOREQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this applica n and that the work will be done in accordance with San Joaquin <br /> County Ordinance Rule nd Regulations,a all applicable California State Laws. <br /> Signed Title/Company 5+e" ('eeioaM / t=dvGFo Swr. <br /> Print Name Za eC4,LW Date x 10F. <br /> DEPARTMENT USE <br /> -ONLY /j Z9 6S <br /> SITE MAP IN UNIT IV FILE, ADDRESS' 2d ata Klli— r <br /> WORK PLAN DATED: O <br /> Application Accepted By d Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'DBY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> Yb <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 />