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an Joaquin County <br /> { Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 <br /> (209)468-3449 Fax: (209)468-3433 Web: wwwsMITIGATIONjgov.org/ehd UNIT IV <br /> N 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 Dec velopment Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> ` f i' pp <br /> WELL Location I � 3-R 5-(" (.)o,�. c :a I�.Cross Street tl2 N 4 f'F'�IL .�. r, Assessors <br /> City &Ca,, {?0 Zlp jSZS Parcel <br /> A 9 <br /> PROPERTY 7 <br /> Owner .uy�j' J0a ji,� (L,V jAddressLy/�' �/SZ,� <br /> v - =2 City ��i:.k f..t� ZiP � hone# ,/ZG°('� 7R-Zb(? (3 <br /> C-57 Contractor >^' Address L3GS W; W& <br /> City Ccc 6'ZiZiP!SZL- Lic#S 2G PPhone# <br /> Cons t1 Suiatr_ 11aa�y// „e,,,IL Address_(,Z2 FCIS ewe 1 <br /> --rf Phone# 9157- Z Lf <br /> GIS Coordinates:X '17- 7-zj S-�� .Y '_R_, (�6 15'Z ,Township i! �t (_I 1 Range Section 3 <br /> WORK TO BE PERFORMED- <br /> 0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# <br /> WELL# 0 W I[.I 0 OVER-BORE. DIAMETER <br /> .'Other 0 PRESSURE GROUT <br /> COMMENTS: GROUT SPECIFICATIONS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> A�MONITORING HOLLOW STEM DIA\\ .OFBOREHOLE_JL I]�MCASINGS 0 MULTI-LEVEL WELL CASING DIA:Zr/ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS C I 1!MULTIPLE C TYPE OF CASING: 0 STEEL PFVC 0 OTHER: X <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL SS TREMIE TYPE TO BE USED: <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: IX'Yes GAUGERS HOSE <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 4,/L;"INOi TE MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH SFO ` (BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSEDdL <br /> COMMENTS: (if YES,list specifications in comment section) <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 Ord' an es, les and Regulations, and all applicable California State Laws. <br /> Signed����"i7�/ ���•e/���-9 Title/Company <br /> Print Name_ r'k ("t,c 4ee.JL, <br /> N'C Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: cIS�E•iJr oL1��lt�s2f)� j!� �.� <br /> WORK PLAN DATED:_. <br /> Application Accepted B !I-{( ,� , 7 Date Issued (Lz--7/67 <br /> Grout Inspection By(� r"T/.F'T'--`— Area 9 r 7 <br /> f'° met Date1�I I p i Final Inspection By Date <br /> Destruction Inspection By Dale <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO jAMOUNTREMITT]ED) CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> �`�pC d <br /> SR#00 S' <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 />