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o� `'• . San Joaquin County ,� _ <br /> Environmental Health Department � �� <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MI IGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> .. ,P NIT IV <br /> �L�FORN Well Permit Application EfvVlRON!L,°tNT <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �; <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,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> �/,, / GAssessors /G D <br /> WELL Location /�77 7 " ,,, 4,C Cross Street OU City Zip !! Parcel# / r O —lO�82 <br /> PROPERTY / / p <br /> Owner T/� .S/i,.,��0t (ro Address/(o727 W"-�""' l�r.(City [u . / Zip U3(9Phon#U�`a.s� <br /> C-57 Contractor Gre Address y'rO &-c 9W City i Zip Lic#�K6G '/7Phone# <br /> Consultant/Sub Cntr G� i; s� f« ddress� �/j'1y,, St,Sf/'Fity L"'c �ty Lic# hone# S�--R6?1 <br /> GIS Coordinates:X 77 80 Y '/a/,.?7 Township S Range CotI�• Section 35— <br /> WORK <br /> SWORK TO BE PERFORMED: <br /> EW WELL/BORING CPT, EOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# C C, F- 0 OVER-BORE. DIAMETER <br /> 0 WELL# PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: PT �D�ins f <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE�USH POINT(GP or CPT)GROUT SEAL PUMPED: Ses 0 No (NOTE: `MAXIMUM F EE-FAnLL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS �5�/d 11 Py 77�. f <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <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 Ordinances, es 'R�/�I and a • able Californian State Laws. <br /> Signed x Title/Company C i`f✓ir/Tl' !Tf �w�'T -7 ��k <br /> Print Name ! �) Ti Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: GUQ-w 8V:,5 <br /> Application Accepted ByAkk6-t­q Date Issued Area �q 7 <br /> Grout Inspection By Date Final Inspection By Date Q io� <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 /> 00 Y3 3 <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 />