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San Joaquin County <br />Environmental Health Depart �II SITE <br />304 East Weber Avenue, 3rd Floor, Stockton,'M-YUE�IITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV <br />Well Permit Application DEC 9 2004 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE4IWd9d)NI rM/EN1 HEALTH <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work desc � his ias 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 />(� Assessors <br />WELL Location 0 1 � d Grarjjj; n e_ RA Cross Street tT nS�e City Trcc.Zip q53T0 Parcel# 2.; f- O X0 - p 6 <br />PROPERTY 1 (� <br />Owner JT S�drx e- Address ;Noo 70!:,+e- ZQ city -T(- CCZip <br />IS3 4Phone# !A5L- I <br />C-57Contractor Cw.C.0.4QC Address&.3Z Qvne-L Clmlt- Cit��ie%10. Zip1S74ZLic*717510 Phone#32-1169 <br />Consultant /Sub CntrA GE Address %I 1 �yau-,j City Lic# 490-Z2-1 Phone# 9(.o7 -/O0(. <br />GIS Coordinates: X Y_ Township Range Section <br />WORK TO BE PERFORMED: <br />D NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') YDESTRUCTION (choose type below) <br />D SOIL BORING # gOVER-BORE. DIAMETER `3 <br />]'WELL* MW - `f �, '� D PRESSURE GROUT \ v <br />D *Other GROUT SPECIFICATIONS ai 191 b 5rsc.K <br />CCiV1MENTS: OVfr-&i\\ to iro}�►1 ��0\4. b�r,1��;\1{,,,:tin G�r�en-4 �ons�'�� cuells) l <br />T PE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />'MONITORING D HOLLOW STEM DIA. OF BOREHOLE_ D ivtULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL D PVC 0 OTHER: <br />D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS D HOSE <br />D AIR SPARGE( OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: D Yes 0 No (NOTE.: MAXIMUM FREE -FALL DEPTH IS 301) <br />D SOIL BORING D HAND AUGER GROUT SPECIFICATIONS <br />D OTHER:_D OTHER APPROX. BORING DEPTH I5 0 30LTED TRAFFIC BOX or D STCVE PIPE _ <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: , '7 00kc,—IA.-,Q ie{ <br />NOTE: OFESI T E EORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />I hereby cart' I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Or s, Ru an kl! tions, and all applicable California State Laws. E <br />A <br />r C <br />Signed x Title/Company - AA2n�- t o r- A V t� <br />Print Nam +i\er Date I�.' 1 C t <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRRSS:_ _ a �(� p <br />WORK PLAN DATED: `t(Z3 b`f <br />Application Accepted By_�4Date Issued ( 2- Area Area 6 Zt <br />Grout Inspection By Mne- v- ^ Date t 1 SL6 o S Final Inspection By ( Date I ZFS <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PE EST #, <br />INVOICE <br />3 �Oz <br />-V 60.c* <br />;.I %Lri8 <br />(a_ <br />S oq o (0 3 �S <br />C-57_ WC_ -WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachmentdo--c_ <br />EHD 29-02-001 <br />6/22/04 <br />