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u Joaquin CouptyIj" ' <br /> Environmental Health Departm�n�� L ��� SITE <br /> :a <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 9. 202 GATION <br /> (209)468-3449 Fax: (209) 468-3433 Web: www.sjgav:orgH+ C� � <br /> NIT IV <br /> `F Well Permit Application ;` i' <br /> n 909 <br /> 15 <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 des ri P1,1Mti_Xss HEA„ mpliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Envir nmen' al I'I; <br /> i , I� �y. sso f5 <br /> 111 WELL Location , _/Il Lac 5uv� �N� ( y k�lbr_ Zip 71' � Parcel# k <br /> I- h Cross Street �. l�r.�, to ' Cit 7'f�,C- <br /> J <br /> PROPERTY <br /> Owner 0;i C, Address 1306 fwe� �-i,AI HCRY� ,, rC��.Zip 1 GG%G' Phone#5-62 i Z-1 �-3,5SH 1 t <br /> I <br /> C-57Contractor iA-I? ��,Z++•{��f.EItnSAddressjols;�. <, i �.i1�: City �(fY,46tF:w� Zipr2i6 Lic# /I�yrPl,one# JI >: , 6�' {) <br /> r k it M <br /> Consultant I Sub Cntr 6ec ye t'j'C a-5-4"ddress 3iS l Op Pw t �CityC W 5 Li#`5—Z C Phone#-//Y'l 6-5 335 <br /> I GIS Coordinates:X Y Township Range <br /> p g r'o e a 5 Section <br /> ii <br /> WORK TO BE PERFORMED: <br />? NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type-below) <br /> 0 SOIL BORING# tip OVER-BORE. DIAMETER <br /> U1NELL# ItLJ 7 U.I'5�,-L 0 PRESSURE GROUT <br /> a*Other.__ I GROUT SPECIFICATIONS <br /> COMMENTS: ! <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING yi<HOLLOW STEM DIA.OF BOREHOLE []MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:X- <br /> 0 <br /> 0 EXTRACTION (0.`AIR HAMMERIDRIVEN CASING THICKNESSA,,_i— �(C TYPE 01F CASING: j]STEEL )WVC n OTHER: E <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL.2�­ � TREMIE'IYPE TO BE USED: XAUGERS 0 HOSE <br /> 0 AIR SPARGE!OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: n Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS_ �� <br /> 0 OTHER: 0 OTHER VIA AgPPROX.BORING DEPTH S C3 ii 6LTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED ktr, '.j I�(if YES,list specifications in comment section) <br /> COMMENTS: �� <br /> �r - <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, Rul s and Regula ' n ,and all applicable California State Laws. <br /> Signed x �f 1 � L:2 Title/Company, <br /> Print Namel�c L�-C� /�- V= i Date <br /> DEPARTMENT USE ONLY oe <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued I I Area <br /> Grout Inspection 8y Date Final Inspection By'1 ` Date <br /> a <br /> Destruction Inspection By Date, <br /> M <br /> COMMENTS t CONDITIONS: jI !! <br /> ACCOUNTING ONLY: AID# I p <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE ' PERMIT!SERVICE REQUEST# INVOICE <br /> f <br /> I MvJ fit, la I � ij SR# �� E <br /> C-57_ WC=WAIVER C-57 Letter of Authorization to sign permit___-_Encroachment doc NA <br /> EHD 29-02.001 <br /> 6122/04 I i <br /> f1i <br /> 4 <br />