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1p' <br /> opa"IN 16San Joaquin County <br /> z � Environmental Health De artment r�j `4 U/ li SITE <br /> 600 E. Main Street, Stockton, CA 95202-3029 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehMAP, Iv- 7 `008 UNIT IV <br /> %FSR �P Well Permit Application ENVIRO ! ; <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUECPE-RPJ1!,/S '1*k'/ 1T j <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 San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location 9122 Snodh Qp ;cf(tau/IV) •ih Cross Street a Sivee� City V-1WA4an Zip %-20(- Parcel# /UZ UI <br /> LLL_ <br /> PROPERTY f <br /> Owner " + tl �CJG i-- Address <br /> uLZ'�roV• P1 fUoYG� 9 City S}bg`h>n Zipt�pz, Phone# <br /> C-57 Contractor Ariinrvn Address $37 4haie Reda City jbnk:fa✓I Zip ;? S Lic# 2"1 Phone# &L' <br /> Consultant/Sub Cntr fliuAhC Inc Address 8 _jh.w 960d City ____ Ukaa�� Phone#a9-�1�'!-i00ls? <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ,>g-NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> SOIL BORING# r-),S 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE L21f" 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL :L TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE yhIPUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS114 JJ) l� L'Frner�+ <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NO (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 /> hereby certify that I ha prepared this application and that the work will be done in accordance with San Joaquin <br /> County Or ' ante Rule n lations, and all applicable California State Laws. / r <br /> Title/Company V ITPA�N1Y�y wQ—R- V1 C <br /> Signed x T <br /> Print Name O F Date J I� 0 0 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 212 <br /> WORK PLAN DATED:_ 1-2,1.-4 <br /> Application Accepted By vti Date Issued 3 1115 j oy Area <br /> Grout Inspection By k1� 1M_r�.� Date `I`l Final Inspection By U\an L=.�*� Date ` b <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3 so 11i"oa z6��q SR# <br /> 3 0'7 ut 00 <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001web <br /> 6/22/04 <br />