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�oaq�i �4 San Joaquin County <br /> Environmental Health Department nc) „§ITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 u 11 \�LC� TION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> ~ ns <br /> �<<F0' Well Permit Application AUGAUw <br /> rI, <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED FNVIRONMENT -,LASPCR <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This appliicat 6rriSs it ' CEompliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> /(��, / D/l� / Assessors <br /> WELL Location /677-7 /-/rte� l'Ci Cross Street li(w/f f City ted Zip Parcel# <br /> PROPERTY n / / �r� <br /> Owner 78 S/';'alo eo Address/(0 77� Nou.�u,�R City [� . LL Zip y�3�C9hone# gS elS/� <br /> C-57 Contractor G1'C Address yS-O &- �� City i T ,et ZipLic#�OS6 1'07Phone# `!.7 S'-3/3-Sf100 <br /> Consultant/Sub Cntr Gepi; i- t« Address,?4V/e,4,� St/-wlCity r/ Lic#// Phone# S -��� -oZ, s <br /> GIS Coordinates:X X7 80 Y -1A1.-Z 7 Township / S Range (D 'r- Section 3-6— <br /> WORK <br /> SWORK TO BE PERFORMED: <br /> EW WELL/BORINGCPT, EOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# elor C 0 OVER-BORE. DIAMETER <br /> 0 WELL# PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: (_ ( T <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 -R(pUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes 0 No (NOTE: `MAXIMUM FREE.-FALL DEPTH IS 30') <br /> XSOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS y$^� �i.'T(9�� �5 /l Pt 7�ir. f e <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 t is application and that the work will be done in accordance with San Joaquin <br /> County Ordi es, d R ati , and all applicable California State Laws. <br /> Signed x Title/Company w' ✓�'G/ C f ��'`r-�l�i <br /> Print Name ? ✓`!/ J Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED:C if"Q CC 7 N D J <br /> Application Accepted By 41k,��- " Date Issued 05 Are <br /> Grout Inspection By Date Final Inspection By Date 4 /3 G) <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 /> q b p L0 5 SR# U l�- <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 />