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San Joaquin County <br />Envir�___mental Health Department SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 ,r ���IGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd—� <br />,L -UNIT IV <br />� <br />`' a Well Permit A lication APp, <br />I <br />P P � l� ZOG6 <br />NDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUfNVjR0(� <br />J(Vr� <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. 1pppp� lin compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Healt(1'6e a6g@ <br />�) �` Assessors <br />WELL Location `7%y� �f4m'?� .� Cross Street Oro ?Q� City K Zip 51/s Parcel# 1L( 35 5J y LO <br />PROPERTY <br />Owner �W(jjr6M1)QZ Address`JIVO e - tlKl'i1 'S� _CityL5&(* Zip 215 Phon 0? <br />4 v +1 f - o4) <br />C-57 Contractors Q�fl�i Address_iSU f>'-ou't gfXl� City�Zip j% .s3 Lic# hone '7 2 5 3i <br />i -1 <br />Consultant / Sub Cntr i�VQrtltt� beo6v,✓ynn Addresse3l ShAW Rd City 6 k Lic# ZZ Phone# zi �' !00 f2 <br />GIS Coordinates: X , Y , Township Range <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING <br />SOIL BORING # r <br />0 WELL # <br />0 'Other <br />(CPT GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />Section <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />COMMENTS: s C(T (occrf crl `, ill Li thele )'o; 1 vkc s 1�c W:2}Gti :;�-hdes [j) P4 c.% _ <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLEIaL 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NIA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: N l� <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL'? fa�r TREMIE TYPE TO BE USED: 0 AUGERS HOSE <br />0 AIR SPARGE/ OZONEXPUSH POINT (GP or&GROUT SEAL PUMPED: XYes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS /orf ( C1 2Pr � 5 <br />0 OTHER:_G OTHER APPROX. BORING DEPTH /00' 0 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 Or4ances, Rues and Regulations, and all applicable California State Laws. <br />Signed <br />Print N <br />Title/Company <br />DEPARTMENT USE ONLY <br />0- <br />SITE MAP IN UNIT IV FILE, ADDRESS: +1()0 rr e rn o rt � St re e-� <br />WORK PLAN DATED: N oV e rrt b e y- 1, 2006- <br />.1 <br />Application Accepted By V 1 c +A r; 0. L. M e_(r in e_V Date Issued 4 Area 1 4 5 q <br />Grout Inspection By rb�� Date 4-2n,0L Final Inspection By V� f14 L, ML °C6rf gz.Date 4121 0 <br />Destruction Inspection By Date <br />COMMENTS/ CONDITIONS: AdVnr1GP.me,h of two CPT 6les2ik 4 a-% about )aL -LPef, <br />ACCOUNTING ONLY: <br />AID# <br />F <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />3501 <br />3503 <br />89 <br />x2'79 <br />3(0 $. DD <br />SR# �O,y 33q <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 />