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San Joaquin County <br />Environmental Health Department SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA� LE LMITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov(:oiJX&dT u UNIT IV <br />Well Permit Application �Ep - I '006 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE I$SUE�R��n�I��r N T I IE ,Lr! <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described'.Thr�' poprC ti66}{isFoade in compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County EnvironmenTt it Heafth Department. <br />WELL Location /19r. w. AveCross Street UF/i&L City /-1A-,Ite,4 Zip �S�� Assessses#sors .?/7.146 - 2/ <br />PROPERTY yMr. AJ * <br />Owner ("{ wr ol�H.�1 Address /D / i Acw City t� .TQC Zip �rlLZ Phone# <br />SAW <br />C-57 Contractor V 0 #L&Aj e- X' Address 2 //o .t).rr•r s Ave.City ,C�,o)ro Zip 2gMic# 70 S'92 <br />Phone# Jb - SG t -74 74 <br />Cn"r/0/'—C-C- &- ql,-f ^r'.FGiti/z <br />Consultan /Sub Cntr_C/ V„1i .77-,,e- Address STt. ioo City .// Lic# Phone 44,41- 2nori <br />GIS Coordinates: X Y <br />Township /s Range 7E Section 32-0 31r fey 2cr <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING (CPT,GEOPROBE)HYDROPUNCH, <br />HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />SOIL BORING # (/�. (e _ [,/O. 7 <br />0 OVER -BORE. DIAMETER <br />�. <br />WELL # <br />0 PRESSURE GROUT <br />DATE <br />0 *Other <br />GROUT SPECIFICATIONS <br />O j <br />COMMENTS: <br />$'do 0( <br />o <br />r <br />�p <br />►t o% <br />SR# Ltq 135 <br />TYPE OF WELL INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM <br />DIA. OF BOREHOLE 2 a 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE PUSH POINT (GP or CPT)GROUT <br />SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />SOIL BORING 0 HAND AUGER <br />GROUT SPECIFICATIONS 95/ 4 Ge•r e f -vto S rr►//w f <br />0 OTHER: 0 OTHER <br />APPROX. BORING DEPTH /S 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 Ordina ces, Rules and Regulati ns, and all applicable California State Laws. <br />Signed Title/Company C„0/„we• '- CLw =uC <br />nn �—� <br />Print Name_ K, f-ful kc Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: I l a1 (,. <br />WORK PLAN DATED: 8 3 df <br />Application Accepted BDate Issued Are 6 Z. LC? <br />Grout Inspection By Date C1\ 1 D Final Inspection By I,&AMw w� Date a <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS UJo4c A l a 0.6 <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />REQUEST #- <br />INVOICE <br />O j <br />*.Ck <br />Zlss �[ Ag • 0 <br />$'do 0( <br />o <br />r <br />�p <br />►t o% <br />SR# Ltq 135 <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 />