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r i <br /> San Joaquin County <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 -U NITIV <br /> Well Permit Application 2005 MAR I I M ' Z <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED S:+H J0/o l:' il` C 0 U N T Y <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. Thi �fi Y('h 0 p c H 7��m1�"1��a�ce with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental HeAh elbartme'ht. �e <br /> WELL Location ,, l GJ `44101?Gv� J Cross Street City /SLC Zip Parcel#rs <br /> ' S. k fz'� 5.�d L /G <br /> PROPERTY � <br /> Owner Jc�h r ldi.tr%�L ,' Gr �l .�Address c fog <br /> City,)c'C+G;/ >y]h-Zip�c�S/ Phone#. c S7 <br /> �•J r r , <br /> / . e/ — <br /> � 5 lo � i0�/ City b /cy /rrzZipLic# Phone# �`' �7�C-57 Contractor JI Address "/ A0Consultanr/Sub Cntr r4c13 Address lSGCity ti G ALic# <br /> Phone#34^•y 51/ <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# ''S /- < i', 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0*Other (7?7 J GROUT SPECIFICATIONS <br /> COMMENTS: I'7 Sc l .hLr�n� At r h <br /> / — <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 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 0 HOSE <br /> 0 AIR SPARGE/OZONE KUSH POINT(GP or CPT)GROUT SEAL PUMPED: )Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> B SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> � CONDUCTO CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: .i PGS. ( CA/11,CAA;'� <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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x "(i�Z Z"��Lc u�{� Title/Company'5�'1 Alr/n:57f ST <br /> / / /� <br /> /'5 <br /> Print Name At1:'�t'�'C'. r�ili�lG71/C 6�'i Date ��/ ``� 1J� <br /> / DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS:_ cZ zall("'r <br /> WORK PLAN DATED: If-3j I C+ <br /> t <br /> Application Accepted By """" r Date Issued Area fi t <br /> Grout Inspection By `1i'l/e&/hDate S 12'f51C)5 Final Inspection By A,%A ,�, Date Z C' <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 /> `((%I -`I C'`' `(c 7 Z I'd 51i SR# <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 />