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ul San Joaquin County <br /> Environmental Health Department ° I <br /> Q. <br /> " 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MII�AShf1N <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd NIT IV <br /> o a� <br /> Well Permit Application EMI WhAFNT HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> PERMITISERVIGES <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 W1,00n WAY V Assessors <br /> WELL Location (�I S , W )50n WADI Cross Street Lnwc 1 5-1,/city S'T &-V7-on Zip `I 52o5 parcel# 15/-255- o7 <br /> PROPERTY �L AA�� �l _ 9 <br /> Owner S' Address �Jcca 'V, �Al;6, /city 5101KT0, Zip9s2pS Phone# <br /> C•57 ConfractorGre GG fl 1i Address�J�-�nwf AD , CityMAfTigr2 Zip Y9 S33 Lic# tYn $ S11— <br /> Consultant/Sub <br /> l Consultant/Sub Cntr_ LrAddress�5S7 SFlgw AD , City s ToL K lgfLic# t2 Phone Zo if - ouV <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING PT GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 'KSOIL BORING# cp-r'`6I cpT'-I 0 OVER-BORE. DIAMETER <br /> b WELL# a PRESSURE GROUT <br /> a`Other GROUT SPECIFICATIONS <br /> COMMENTS: SEF 'NO AfXtiuU) WnrK D/I},) (11���os C Re ' n tivc,fF 20" (�Z�106� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPEC FICATIONS AJ <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE ) °^a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS NI�7 TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: 1Jb4 <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL Ib 0 TREMIE TYPE TO BE USED: GAUGERS I+OSE <br /> a AIR SPARGE/OZONE 'USH POINT(GP or CPT)GROUT SEAL PUMPED: a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS_ _P rT1 q ,O /�/2h <br /> a OTHER:_5 OTHER APPROX.BORING DEPTH I ine) r g 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 Ordinances, Rules and Regulations, and all applicable California State Laws(..'' <br /> Signed x 7 - C� Title/Company J�i�6 .CT b�:435IS i / 6 C- <br /> Print Name IjMn'TMv J. ��If1IH,/ Date Ob1L3 � 4 � <br /> DEPARTMENT USE ONLY —� <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 101S, 6 Ltl (1/6o <br /> WORK PLAN DATED: <br /> Application Accepted BDate Issued <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 /> `13 00 SR# 00g72 18 <br /> C-57_ WC--­-WAIVER— C-57 Letter of Authorization to Sign permit_Encroachment doc_ <br /> Ex0 29-02-001 <br /> 6/22/04 <br />