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San Joaquin County <br /> > ` o <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 9-11++115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location_ 3524 Zer2N u� l.4 Cross Street �y' S�- City 54(�_ s� Zi Assessors <br /> p 9'520 Parcel <br /> PROPERTY. 9)820 Phone# _3 <br /> Owner 3bDO <br /> Owner Q€1;iiA djj �vcL� Address, �y /,� QCity CRFt� Zip <br /> C-57 Contractor GW 'Tc- (f� Address 9 J 6 40cuQ.( [J City A6e4zi./�Z-Zip 49 y53Lic#k8901hone#927�g313-5-870(, <br /> Consultant/Sub Cntr_ YLtd5C5rL5 Address ZIZI I4,��Z le "� TJ Lic#P'Phone#9Z6'� 4-_I-3 , <br /> v}}��°(J ouH <br /> GIS Coordinates:X ,Y Township f►J Range Lr Section_ 3 <br /> WORK TO BE PERFORMED: <br /> gNEW WEI=/-BORING (CPT,GEOPR BE, YDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# {1 lP(�T� OVER-BORE. DIAMETER <br /> D WELL# 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: See NAte-6-0h 11,ccL6-e t) <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2."' 0 MULTIPLE CASINGS 0 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 TREMIE TYPE TO BE USED: 0 AUGERS HOSE <br /> 0 AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: )(Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 5o' -1p116" 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED X O (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 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi ces, R es nd Regulations, and all applicable California St/ate Laws. / CID <br /> Signed // Title/Company ptokpG�� ��o P���IByL�j_� <br /> Print Name Fte���=�tG�, I<;,,,�Zp� Date66 <br /> DEPARTMENT USE ONLY �. <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �r <br /> WORK PLAN DATED:_ °.S�� I n C 6 v <br /> r <br /> Application Accepted By ADate Issued /��/ b (0 Area 7 <br /> Grout Inspection BDate I z i6 6 Final Inspection By L ,j Z. (p 6 Date Z <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 /> SR# �a3S <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 />