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��1VE <br /> pP.quIN.,c pan Joaquin County <br /> R Environmental Health Department APR — 3 LU SITE <br /> 600 E.Main Street, Stockton, CA 95202-3029 " l�lftlGATION <br /> U � � <br /> p�` ('� n' n r <br /> 209 468-3449 Fax: 209 468-3433 Web: www.s ov.or eh UNIT IV <br /> ( ) ( ) Jg �/ Et�,�r1iT;SERVICES <br /> 9`'F�R`° Well Permit Application <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 /> Assessors <br /> WELL Location 30LI(4 3nu4j, L, hu"33 Cross Street puyhatn Fjetq 96ad City TrnZip 9s•36V Parcel# 2SS-3io-20 <br /> PROPERTY <br /> Owner John jrinLle Address Q95-st N055on Vt cd City Ty� Zip 4sib4 Phone#909- G 1(,N-9q4� 9 <br /> C-57 Contractor F1djnnPPr1 6eCEfte;y=nm4[.f Address $3-) Show Roc?rt City e}Mebp Zip$5j15 Lic#i, �Phone# Soh Lib-1 iool, <br /> Consultant/Sub Cntr IMIL)Anr,,d ddress 837 -3haw Rnne4 City$�_Lic# baLL2'1 Phone#aoa-Nu-1.iootg <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ., 'NEW WELL/BORING (CPT,GEOPROBE HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> `,g SOIL BORING# 1brbLAl R1Z0 a OVER-BORE. DIAMETER <br /> a WELL# p PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE I.DS" a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: ')jfi- `N <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: O STEEL 0 PVC O OTHER: 1jjIA <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: o AUGERS a HOSE <br /> p AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes 4No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') _rl- <br /> 'SOILBORING aHAND AUGER GROUT SPECIFICATIONS Tup< -LIvr}lQ�n�{ }gyp Ayry� <br /> a OTHER: p OTHER APPROX.BORING DEPTH :31 a BOLTED TRAFFIC BOX or p STOVE PIPE `f1 <br /> CONDUCTOR CASING PROPOSED On (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. L-7- <br /> 48 <br /> s48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. V-� <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Or ces, F34le a Regulati ns, and all applicable California State Laws. C <br /> Signed x Title/Company !/ 91-eS/66-lz <br /> Print Name e 1 E Date 60 j�ryi �OOFj <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: S I Z It V S_ r4l0y 33 r 051-7 U-2 - <br /> WORK PLAN DATED: /2'� i ��'�L� i)d-&x2 c t <br /> n 31 o* <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Dat Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: C✓/2 G✓Q <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> A9101 CYI- Ni o` 1,1 M.� <br /> SR# �J( -ql 3`f <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 web <br /> 6/22/04 <br />