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� "A., N San Joaquin County <br /> .�.Q;; .......,c, . <br /> >< >==, Environmental Health Department SITE <br /> 1 304 East Weber Avenue, 3rd Floor, Stockton; CA 9520 ftATION <br /> (209)468-3449 Fax: (209) 468-3433 Web: www,sjgov.org/ehd <br /> IT IV <br /> >. . <br /> NOV 7 2nn� <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEW4RC WyENT HEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. %W'TAfiR"nn compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> --/I '�5'+` ( ( Assessors e <br /> WELL Location I �. IV•NXh tS�Au>; clt. Cross Street HULA City 64odklA Zip Parcel#137-z(0- OS <br /> PROP <br /> Owner CAI OZQiAddressKO) dol <br /> �1ShOIte- -cit LoAa kZip 090LPh <br /> one#!��'9SI'4(P.0 <br /> C-57 Contracto SOY1aY5M IL&fddress0 A ipJ Lic#Bo5 <br /> 424.Cit06 <br /> Consultant/Sub Cntr&Y1 &A�e ddresslDDKky46Kr� ity*ekh%Lic# ;Phone#20'Z%-0S1g <br /> GIS Coordinates:X 'Y 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 BORT G# 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 []MULTI-LEVEL WELL CASING DIA:-E_ <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: MA IM,,U(�M FREE-FALL DEPTHS 30') <br /> O SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS_)e ASe— See � A e4 l ea Qljo+QM.YI1`.S' <br /> 0 OTHER: (1 OTHER APPROX.BORING DEPTH nBOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> �I y�' ,-1 CONDO TOR CASING PROPOSED �°5 (if YES,list specifications in comment section) <br /> COMMENTS: 6 (A �t(1'�� , !4/- , (tp <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 Or inances, Ru s Regulations, and all applicable California S,t�att� Laws. <br /> Signe Title/Company <br /> Print Name Date I I 1 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: 5 jL..- Zoe,5' <br /> Application Accepted Byc»v e• h Date Issued Z/a 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'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> z79-3503 06asS78-fZ79 Cr �r %/ `7 D� SR# 001457$4 <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 />