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San Joaquin County <br /> Environmental Health Dep -tment SITE <br /> 600 E. Main Street Stockton CA 952 614--, , -j <br /> 1 , MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org[ehd UNIT IV <br /> Well Permit Application -` " %!,08 <br /> NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM03% U cn, <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install thew ?r 4 rlb�d.,phis,application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Reaith`bepartment. <br /> Assessors <br /> WELL Location 2122 'i�,,-t441 A,K,064 MA4 Cross Street 2'L* S•y.e.e-I City Nbekf-nrr Zip S� Parcel# 1(s9-1b 2 61 <br /> PROPERTY <br /> Owner RCLyoh tuhi�e Address,2203 9&A Awa i IJOu City 9fp6k!•nh Zip gS2clD Phone# 209-q&N-y371 <br /> C-57 Contractor Hilehell DnKno Address '79Co Ljr rJ f t &CMUJ City C-uako ZipqSSZG Lic# 1,7:2Lhl Phone# '16-7-inti`]-Y0146 <br /> Consultant/Sub Cntr eALj Grt nurd�h r�i( Address ��7 4 i�) A'Uc2cI City.9P&11h)n Lic#W0S 2 a1 Phone# 'Jp�j-yCa 1 IUo(� <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ANEW WELL/ BORING (CPT,GEOPROBE, HYDROPUNCI 1,HAND-AUGER,OTHER*) g DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> SWELL# MLU-'1,MLu-Fr, Mw- , Mit1 IU /lW-l1 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> gMONITORING -HHOLLOW STEM DIA.OF BOREHOLEE3'as'1 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL >ErPVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL :2(01 Onj 75r TREMIE TYPE TO BE USED: 0 AUGERS .THOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS TUCX 'Ili 141CthC,� C1rMIn+ <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH Sb GVlcl I I 6� 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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ord' noes, Rules and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company .'/i:::zt p�{S)L�f'►?��14CI U'�tyl�'Prl�j�J�L�11 Uryah mt1 EctL��9C. <br /> Print Name K� Y Date ,I 4-0 0 <br /> DEPARTMENT USE ONLY FILE <br /> C <br /> SITE MAP IN UNIT IV FILE ADDRESS: Z I z z 5 <br /> WORK PLAN DATED: 12, Zti n <br /> Application Accepted BDate Issued IS I �S Io Area <br /> Grout Inspection By VDate 19 (e,-e- Final Inspection By_ Date 3(;-,1 o <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 /> 35-013 $2gq,or✓ Z69}� ( 3�its�og SR# Ca3 �3y <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 />