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SAN JOAQUIN COUNTY SITE <br />EN .AONMENTAL HEALTH DEPARTN._�.JTU ITIGATION <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202-2 C Gc Vp—? ' Iv <br />(209) 468-3449 - Fax: (209) 468-3433- Web: www.co.san-joaquin.ca.us/ehd 71_� <br />APR, - 5 ?005 <br />WELL PERMIT APPLICATION FORM <br />ENVIRONmEN1- <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEll ERP4+��npHLALTH <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is M� A urri' mpliance 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 ;106p C f.CEEwu+�� Si Cross Street L/9UsloE City S-e-bCA7d"I Zip Parcel# /y/ <br />PROPERTY Owner .SFiL -' ir5ePI t^ -Iv Address j83 PtlEASAM 0CouCCityS'7Jc 'r0j Zip9Sx..)-7 Phone# 913 1F3%j <br />C-57 Contractor G.kA-j u.) AIQN. Address P,O • Row .?-?4 Cityi2io V,STA Zip`/ S7/ Lic#7/oo7`%Phone# 70737f <br />Consultant/ Sub Cntr 47G /i-,SrOCIhifs Address ///7 GOAL Pi4C.r+ A✓ECityf 0-P6_S%o Lic# Phone# ,-JyZ LZ/ <br />GIS Coordinates: X , Y , Township Range Section <br />WO K TO BE PERFORMED: <br />Yfl EW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE - DIAMETER <br />LL # 0 PRESSURE GROUT <br />Is -Other: jeEPc,4CCwC— Grout Specifications: <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />AONITORING OLLOW STEM DIA. OF BOREHOLE „MULTIPLE CASINGS? 0 YES g4e WELL CASING DIA: A <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SGN Bio TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ? ,So ' TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: R -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 0009 GS 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED?—"'D ( if YES, list specifications here): <br />*COMMENTS: �� t V �� Y ��r /� 7� i F '�� 1- j <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED 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, <br />%Rules ang Re lations, and all applicable California State Laws. <br />Signed x �o y __ Title/Company !% 6=r IS -,1 4j -C ,&"c -A 7CtS <br />Print Name ��_ lf?F-or EW Z Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: - <br />c <br />Application Accepted By •v- Date Issued It > /�= = Area <br />Grout Inspection By W�4rc_lDate Final Inspection By �,� 444 C4-- Date <br />Destruction Inspection By Dat <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# <br />FAC# 10 K,00,q t 713 <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICEREQUEST # <br />INVOICE <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit <br />EHD 29-02-001 <br />8/27/2003 <br />Encroachment doc <br />WELL PERMIT SITE <br />