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r O.pQUI_V�O ao n Joa uin,cdu-nF I L Id, C 0 PTt� i�tt. ae[ ►, urrr, <br /> >.• 9 tY <br /> Environmental Health Department SITE <br /> 364 East Weber Avenue,3rd Floor, Stockton CA 9.,52¢2' L�l �TIGATION <br /> 1•'. .' ff � <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov_orIVIT IVFr Well Permit Application 'R . W9 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISS f 1, <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work describe TPs' i n compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environme1l�>i��i�� �� <br /> _ ssessors <br /> WELL Location .Sd N. �,�1r 5o+N WaE. <br /> _ Cross Street lll�,vJlrt City 5 ?�GC,�ay� Zip 1710.j Parcel# <br /> PROPERTY 1, ." 5., <br /> I Owner � �t Cc Address,�il�fi �11,�„3f H-J�_CityS.•rfzj Ire 5C4 zip o6/0 Phone# -6-2 iZ_/`3S(�/ <br /> CS7Contractor ltlVS{� G,Zv^�jD t'n Address�l� . �. (�c��}yi CityL11' lF:rhZip <br /> +� ( 6 4 <br />{ <br /> Consultant lSub Cnir6e, Lra�SC tis 4 Address?IS1J},fe: .� CityCe5 �( Llc#`Si ZC Phone#7/01L6 <br /> GIS Coordinates:Xy <br /> Y Township ! RangeSection <br /> I WORK TO BE PERFORMED: <br /> Q NEW WELL!BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTH *) i DESTRUCT ION (choose type below) <br /> Q SOIL BORING# `OVER-BORE. DIAMETER-! <br /> 'WELL#_ Yh WPRESSURE GROUT r <br /> D*mer f'GROUT SPECIFICATIONS <br /> COMMENTS: I� <br /> i <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORINGIOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS 10 MULTI-LEVEL WELL CASING DIA: <br /> fi <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS 5L S« TYPE OF CASING: p STEEL } ,PVC D OTHER: <br /> o VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL li~I�'i TREMIE TYPE TO BE USED: O AUGERS 0 HOSE 1 <br /> 0 AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes No (NO'TE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> d SOIL BORING a HAND AUGER GROUT SPECIFICATIONS V V4G,_,( <br /> 0 OTHER: fl OTHER APPROX.BORING DEPTH �O I+, Q BOLTED TRAFFIC BOX or o STOVE PIPE <br /> CONDUCTOR CASING PROPOSED fl (if YES,list specifications in comment section) <br /> COMMENTS: <br /> L <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, Rule-sand ReguI . ns,and all applicable California State Laws_ <br /> Signed x_ � TitlelCompany�o /�� fip��f�5f � "']`.r�—�— <br /> �y �/ II <br /> Print Name i�r L�e v-d A- It o S Date _2 -'' 2-clo i� I <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> ! <br /> I! WORK PLAN DATED: 1f <br /> li i} .ii <br /> Application Accepted By Date Issued 7~ ' Area <br /> Grout Inspection By Date Final Inspection By it ' Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: '( <br /> yy o I <br /> ACCOUNTING ONLY: AID# <br /> FAC# i <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC-D BY DATE PER I SERVICE REQUEST# INVOICE <br /> Sa w� rte. !n , �g G,� z. 3 sR# �� // <br /> C-57_ WC ✓WAIVER_ C-57 Letter of Authorization to sign permit,____,Encroachment docAM <br /> FHD 29-02-001 <br /> 6/22/04 } <br /> i! <br /> i. <br /> a <br />