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• • o FILE COPY <br /> Pqury.... San Joaquin County <br /> z•'' °°2 Environmental Health Department <br /> It {� 304 East Weber Avenue,3rd Floor,Stockton,CA 95202 •/*TI AT�� <br /> �' P�t (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/ehd elvVI,90 U I40by <br /> Well Permit Application PSS lc <br /> es <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED FRl9 fs TN <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Cha er 9-1115.3 d the Sl ndards of San Joaquin County Environmental Health Department. Y,51,320 06 <br /> r�ot�/� � �,p,�p Assessors <br /> WELL Location `&91-O4W•Y 't!r ~' sStreet`1/l/vim - City Tt�- Zip Ot.537� Parcel# Z— 1p00 <br /> PROPERTY `508 E•u1+�t7'WRsf���'�''` —�— 3z( - ZOTO <br /> Ownery •csj"aD.fUll,ddress l7( � YH or^ -� Glory City L-r.x( or'e- Zip 44 "s'/ Pho�ne^## <br /> C-57Conlraclor V$r,a Z;6xl' S Address 103 7o City Zip 9Sz41Liril�hone# 36S-�6o� <br /> Consultant/Sub Cntr �i '+V`-�J a1,� Address — City Lick — Phone# <br /> GIS Coordinates:X 3T• T9> .Y 'I-•1-ST ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 4 ANEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> a SOIL I Co. ( 0 OVER-BORE. DIAMETER <br /> MJ-0- <br /> G OUTSUREGROUT <br /> 3 p�6d 1#4 ISt'o0 G!• GROUT SPECIFICATIONS <br /> ' 1'�ctSMwrs: oo Q• �O�- 1 PoU-1 laC-3�A <br /> I <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ff MONITORING RHOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS5c- `IO TYPE OF CASING: 0 STEEL JPVC 0 OTHER: <br /> 0 VAPOR WMUD ROTARY DEPTH OF GROUT SEAL" %% W TREMIE TYPE TO BE USED: JAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: -#Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS (Z °'"4 <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH ^• k 7A 0 BOLTED TRAFFIC BOX or gSTOVE PIPE <br /> I1 CONDUCTOR CASING PROPOSED ry, �(if YES,list specifications in comment section) <br /> COMMENTS: � X S 4Z:' —tcx-� — L MAtQ <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 dinances, Ru s anO Regulations,and all applicable California State Laws. <br /> Signed x ! �J 4 Title/Company `i j' / VLI ✓S w rV e ' <br /> Print Name 1)81--Jy`.)�S L61 kc-ylr— Date e" - 6—a7 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �� N <br /> WORK PLAN DATED: ®� <br /> Application Accepted By Dale Issued Area Q46 <br /> Grout Inspection By <br /> Date Final Inspection B SO"`a ale <br /> Destruction Inspection By D <br /> COMMENTS/CONDITIONS <br /> ACCOUNTING ONLY: AID# FAC# <br /> PECOD2ES FEEINFO AMOUNTREMITTED CHECK# RECD BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> k7u7 ? 2, � ( �­6 SR#©J� S <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Enc men do ' <br /> EHD 29-02-001 G <br /> 6/22/04 <br />