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San Joaquin County Y <br /> Environmental Health Department <br /> 304 East Weber Avenue, 3rd Floor,Stockton, CA 95202 <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> NON-REFUNDABLE PERMIT EXPIRES 7 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 /> WELL Location 1 V UPAssessors <br /> a city L �� N Zip ��� <br /> Parcel# j4a--702-0?-1 <br /> PROPERTY n p to D <br /> Ownerr�� Y��'�nn(���fA1y5 Address �7c1�/�" Iv QVV► �/�� City_S Zip 61S-2& 2� ig-31.4 7G <br /> C-57 Contractor �.-�i(A(I-e_ k�f�Address .-�. Ooy-o In i(clecity(Af Q. Zip q�7�.Lic#�0Phone# '"69S jt <br /> Consultant/Sub Cntr Q0V fC✓1 �9��lfJ j✓i,S Address IS*G S ry1t�/!✓y�ij,�,r Cityj:�:a-k,,AtaLic# Phone# 71-4'-43/-410o <br /> 1 e7 17 <br /> GIS Coordinates:X 9670Eis-fruil 3 335 Y Int°I bo,n U-JSCOjownship _Range l.LL�Section <br /> doh W&4- <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) ESTRUCTION (choose typg below) <br /> 0 SOIL BORING# VER-BORE. DIAMETER i�l <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: VA U�q <br /> TYPE OF WELL IN TALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 109ONITORING HOLLOW STEM DIA.OF BOREHOLE-ILL 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:2- <br /> a <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS_ C61 (7 TYPE OF CASING ®STEEL VC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: flAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 2 ®BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <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 Ordinapges, Rules and Regulations,and all applicable California <br /> State Laws. <br /> Signed xTitle/Company d"/ i 2-6 06 <br /> // �rPck <br /> Print Name .r-..L Date / G� �l� / <br /> DEPARTMENT USE ONLY -S <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Mti <br /> WORK PLAN DATED: ,( �+g <br /> Application Accepted By C XGd=/�®-�"'4-� i� Date Issued `Area ta{- <br /> Grout Inspection Qy Date Final Inspection By <br /> Destruction Inspection By /4,. Date AO /V O S V1KON �fl <br /> COMMENTS/CONDITIONS: ,Z0-de7 ® 6w*/- <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <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 />