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,o.P`�`•'!'"..�o San Joaquin County <br /> Environmental Health Department s�� /� TE <br /> 600 E. Main Street, Stockton, CA 95202-3029 FNS. ©� MAIATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.orgl dll,,/ <0, UNIT IV <br /> Well Permit Application licF f/F <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 /> *} 1 Assessors <br /> WELL LocatiX 1 Of `'C-PA �"�<< Cross Street 7V4 City ✓"ItA�/S Zip arcel# 255)?Cr/5 <br /> PROPERTv _ <br /> Owner4<Ak_�ff(C. (,� Address�Q�S�C� W ZoJRCh Q,�City-P44� ip!�S Phone#�J_ <br /> C-57 Contractor&_ j R0 / /Address / City Zip Lic# 71 P hone# <br /> Consultant/Sub Cntr 40se heUIn�LIf�,II3 Address *16/5�Sb&,l ity QC k4.d, Lic# Phone#5_/0.2$5.2-�4y <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# a PRESSURE G GROUT <br /> Other ROUT SPECIFICATIONS <br /> CAT ONS <br /> /z . NC, M$ <br /> COMMENTS: % /it/CcfmrS `{S�— Grdtilrd 7D d ,71 44lb�`ie. <br /> e <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLEZZ/ 0 MULTIPLE CASINGS 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: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') 41 <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS O <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE -- <br /> CONDUCTOR CASIN ROPOSEQ - (if YES,list specifications in comment section) ON <br /> COMMENTS: 1�4/h�f � 1�` l�.lXy(ye/W l — JJJL.IJ� SIto <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. L'+ <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company (S� / �LcShfI�PL Ca1tS���kn <br /> Print Name Date $ 3 �— <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: S 00 /4!f& 33 <br /> WORK PLAN DATED: ° �1JR1�Ja <br /> Application Accepted By (.� K�n rC�C Date Issued 9/j0l 07 AreaQ� <br /> Grout Inspection By Date Final Inspection By Date <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 /> o�-9al 85 y co 9//0/0 SR# 00s7 Y'82- <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 />