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-T <br />San Joaquin County pPY EVES <br />E� <br />Environmental Health Department <br />1A 4 tiZ\y6 <br />ORIGINAL <br />SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 w\P\A RIITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd POu\1" N�P� 4JNIT IV <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />sp, �o\k vc"Ao AMEN <br />t7 tJ <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 �an Joaquin County Environmental Health Department. <br />ZZ �S F- G� } Assessors 41 _Zlq-02� <br />WELL Location �•�Y•eVW(7� Cross Street /r��4-1 City Zip Parcel# <br />PROPERTY <br />\fe�ecJCityTVW ip ��Phone# 5) SpoOwneS70P 1011�Addr,ess 4% <br />C-57 Contracto ``l (Address3 �21� ��,cr/. Clrc(e Ciai ts-k Zip 74?-1ITSI 0 Phone#�g <br />1,� 4q]4 $J"MD'PLP #S ty�1�DiZAD �( t� 307 Phone# 916 ? -Z.IW <br />Consultant /Sub Ir�ON �A1AYO� WtGCI'�0:� Address Y�1Z • ,Cri T� <br />GIS Coordinates: X Y — , Township Range Ftp Section 31 <br />N <br />WORK TO BE PERFORMED: <br />NEW WELL 1 BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') 0 DESTRUCTION (choose type below) [� <br />6 0 SOIL BORING # 0 OVER -BORE. DIAMETER v' <br />WELL #_ MW --7 0 PRESSURE GROUT <br />0 `Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS X <br />MONITORING HOLLOW STEM DIA. OF BOREHOLE <br />tt �0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 2 �c� 0 <br />0 <br />EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS le1ece 40 TYPE OF CASING: 0 STEEL / PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL � TREMIE TYPE TO BE USED: )(AUGERS 0 HOSE Q <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: YeNOTE: MAXIMUM FREE -FALL DEPTH IS 30') 3 <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Aea-t tGvnne-v%A <br />0 OTHER: 0 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 Ordi n s, es and Regulations, and all applicable Californ' State Laws. <br />Signedx �� Title/Company (�i ��1 b y (� ri t1* "-"" "�t^`�l <br />/7 /j <br />Print Name �� P61 / ;) 40' Date Z <br />DEPARTMENT USE ONLY.. <br />SITE MAP IN UNIT IV FILE, ADDRESS:Z 6, <br />WORK PLAN DATED: Z Z005 <br />Application Accepted By Date Issue.Area <br />Grout Inspection By Date Final Inspection Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />J' D <br />s <br />�2��/�j <br />SR# & Ti <br />C-57 WC= WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment docAIR <br />EHD 29-02-001 <br />6/22/04 <br />