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o Osan Joaquin County <br /> �i Environmental Health Department ° I <br /> " 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 �M IT19 N <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd SUN NIT IV <br /> ��FOR Well Permit Application ENP iT�B T 1400H <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> RVIGES <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 Pan Joaquin County Environmental Health Department. <br /> W.Lfon WA / <br /> Assessors <br /> WELL Location Ion S . Wit )Sol) �NIGA Cross Street fnARKen lS1, city STo,-k'nn zip `152o5 Parcel# 151-253- a7 <br /> OwnerFIR ERTY Address C7JQ �I, UU��k�n `City S�ocKTr`n Zip9S2PS Phone# Z99 Ib Z..� 327 <br /> C-57ContractorcPi 1I Address! 5n dawF RD , cityAA rTrA, —zlp Y9 Sn Lic#VtYg7Phone 'S/ ^ 51ioo <br /> Consultant/Sub Cntr R.Ce.I.. . Address83'7 SH4w A0 , city$Tol KTa&ic# ?_2 -/aPhon 20 y Qy <br /> GIS Coordinates:X 'Y ,Township Range Section <br /> WORK TO BE PERF R ED: <br /> NEW WELL/BORING CIT G OPROBE,H DR�PUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> XSOILBORING# C 'FS QC T' COVER-BORE. DIAMETER <br /> b MLL# D PRESSURE GROUT <br /> 0.Other 11 GROUT SPECIFICATIONS <br /> COMMENTS:_SZF FHO- I�o rVAId '1 WW'K O1Arj cllb5 �sJ RQvw'X.n wof >. plA,v (�23r c <br /> TYPE OF WELL INSTALLATION TYPE T=SPEC FICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE J ° p MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: N/A <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NIA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: NIA <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL b a TREMIE TYPE TO BE USED: 0 AUGERS BIOSE <br /> 0 AIR SPARGE1 OZONE 'USH POINT(GP or CPT)GROUT SEAL PUMPED: as 0 No (NOTE: MAXIMUM FREE-FALL DEPTH 18 30') <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS ArTl qA p Ty�� <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH line)' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED_t/a (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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x 7 - Title/Company 1 f c.i said IS i / A- 6. E- <br /> Print Name 1jivinTHv J. coo) Date 04�2_3I o 4 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: /W S <br /> WORK PLAN DATED: 7 <br /> Application Accepted By�r/ -r-� d�.fi� Date Issued G Zr OrP Area <br /> Grout Inspection By a Date 81'21-2 706 Final Inspection By Vll ' N. Date 2Z U <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> `13l• 0o U0111) , 1, sR# 004j7218 <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 />