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,��` "'" •�a San Joaquin Coun <br /> ty <br /> «�M a Environmental Health Department SITS <br /> [a `{ 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 r, I <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> egcsR�'`P �C 33 A NIT IV <br /> Well Permit Application 04 <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 Deve A4§," e,Chapter 111 the Standards of San Joaquin County Environmental Health Department. <br /> O�,f�v"�t�{, i� <br /> WELL Location Cross StreetAssessors <br /> PROPERTY - <br /> City ^ Zip g52dZ Parcel# 15-:J ot'1 - <br /> Owner �c I o„g Address 3 q 5 Cit�� — !� <br /> _ Y Zipg�2a'� Phone# 2 � - zOO <br /> C-57 Contractor Address �(� I/r?•„1 I, <br /> Consultant/Sub Cntr a E Address_ZI2 &f” <br /> a�,�.City i� n Lic#_,r�p2Z"1 Phone#Lzpg)YL'7-Ion(p <br /> GIS Coordinates.X 'Y Township Range__ <br /> Section <br /> WORK TO BE PERFORMED• <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') DESTRUCTION (choose type below) <br /> 0 SOIL BORING# OVER-BORE. DIAMETER <br /> DWELL# <br /> O'Other p PRESSURE GROUT ` <br /> GROUT SPECIFICATIONS c}�m <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL d PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 11 AUGERS 0 HOSE <br /> n AIR SPARGE/OZONE p 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: a OTHER APPROX.BORING DEPTH (]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 Title/Company r-Qef��[- I\ <br /> Print Name---,,(-. b Date_ I- q-CS <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: , <br /> WORK PLAN DATED,:!_ <br /> Application Accepted By 9�7 _ _ Date Issued /D V� Area_ 9q? <br /> Grout Inspection 13y Date Final nspection By Date <br /> Destruction Inspection By Date - E'S V 1 <br /> COMMENTS I CONDITIONS: LO 11 X4 0 <br /> —0-5 <br /> t � wCj'[- <br /> ACCOUNTING ONLY: AfD# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3S-02- 60,!0 #6,0 os OLI 6 2�0 641� tz.1161'067 S R#60 iv90.' <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 />