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r <br /> as <br /> San Joaquin County `..� <br /> ; Environmental Health Department o SITE <br /> ::.::;::;.::.::......:.::; <br /> ........::::>:....:::>:: ::>:.,::. IE8 ATI O N <br /> �� �3 304 East Weber Avenue, 3rd Floor, Stockton, CA 9520 <br /> A,= ,+ (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd IT IV <br /> Well Permit Application NOV <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEWUTA(*MENT HEALTH <br /> p <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. t t> liiTA60,016nn compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 125 - IY Q Arl16 Assessors <br /> WELL Location A <br /> IAS �. - Cross Street Aua�Q City�'������'t Zip Parcel#f39'2-t0' 08 <br /> PROPE Y /1 (� ,t _ 4 <br /> Owner o9 C4tj =0Y1f1Id1 Address 401 L0II/ShOIt,I✓ CityLo(m &AtkZip (�D�Phone#� •951- 110 <br /> C-57 Contracto&5D11Q4 Il.ILOLAddress �O t4.02at + 55t- Cit W i�atJ 7 Lic <br /> n_ /_ ,�� Te <br /> -t- �p < t,'_,j q Y jjArj ip 7 ti f8oz�Phone#Ba!i6 $'2424 <br /> Consultant/Sub Cnt_tftkIlL QX'tllTeA. Addressj68 ft I1kWCS1 C;l ity.�l� ��1 Lic# Phone#2.09^Z94-0�19 <br /> GIS Coordinates:X Y T� Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORIf # 0 OVER-BORE. DIAMETER <br /> X WELL# 0 PRESSURE GROUT <br /> 0 Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS r� <br /> X MONITORING HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEELPVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE U D: 0 AUGERSHOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MlA(IMwU'_M FREE--FALL DEPTHS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS_-? Sef, I tVAe-K! . I}l( o; yy.,rn <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> to (1 .�yy� ,"' CONDO TOR CASING PROPOSED °� (if YES,list specifications in comment section) <br /> COMMENTS: % (A <t' +W' i1tS/W , Qk6 aeY1'1e*- <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I hav repared this application and that the work will be done in accordance with San Joaquin <br /> C Ordinances, Ru sRegulations,and all applicable California S,t�att� Laws. <br /> Signe Title/Company <br /> Print Name Date ( I 1 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: 5 �jL//<+� Zoe,S <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date h' Final Inspection By e <br /> Destruction Inspection B Date <br /> COMMENTS/CONDITIO S: /`/ <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3 63s-- ---'Sw 368 e,6 FS--7-97-079-9 <br /> 279-3503 06 578- IZ79 C..A17w OI' SR# ��145794 <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 />