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,oAavi.'.° 0 <br /> San Joaquin County <br /> y AEnvironmental 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 <br /> Well Permit Application 2 <br /> k1 `1 ' �l t; <br /> NON-REFUNDABLE PERMIT EXPIRES 7 YEAR FROM DATE ISSUED S A se�ys`� '''C)t�i1`�fi i nL <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This apptie�i�}npA�f�'i�i`COmp it ante with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Heal p rtfAT <br /> er . <br /> II� L Gv•a2 n a( S-L /_- ? Assessors <br /> WELL Locatior►S S�k. 70 Sr,�f} D�tGtJ7 $� Cross Street ,7-/•P S�-. City s��7t>Y/ Zip 7�Jo�O�o Parcel# <br /> PROPERTY, r r <br /> Owner Rn,tY Z+- ;i 1 tt,•-Address 1 >� +/1/jf,"�Ae(o) � <br /> / � /- City�> r; Zip 5-�:, Phone# t <br /> C-57 Contractor�LI51//&2dnV,,rryt�t� Address�1.SnQ/5 pla6e City 41 rr Zip�jo?5; Lic#41M65 Phone#def,77c?•3-571 <br /> Consultant/Sub Cntr&dO &Jitf6G e4 W5td Address q75W'5/ree� .5Ve.q0 City Lit# P h o n e#S/D FG 30341 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> g NEW WELL/BORING CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> ,SOIL BORING# . 0 OVER-BORE. DIAMETER <br /> '$WELL# 0 PRESSURE GROUT <br /> 0*Other / GROUT SPECIFICATIONS <br /> COMMENT4y <br /> ?r GA) 4'fn�s /R,' 11'vrinc Gvt��031 �/ti?aiDrfGwf S7 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 'HOLLOW STEM DIA.OF BOREHOLE &" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS: GC AFD TYPE OF CASING: 0 STEEL VC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ✓3 TREMIE TYPE TO BE USED: R' UGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ZYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS /Ca4(- "htxv'c�] <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 30 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> /•� <br /> / <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: �0;g t �J <br /> c Xjn,�S �) Q /..t�r�/�I Qblrli� � 1 _ �" <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�O,redinnances, Rules and Regulations, and all applicable California State Laws. / / <br /> Signed x !'c��I//GL(/�_�ra,� Title/Company_ A,4r�/O!,'/59 gecSq. -& �G <br /> Print Name Alat . ,/N[Gll Cwq yj <br /> Date—o2 /(0 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> ,. $r <br /> Application Accepted By i 1. v ,r cw Date Issued ? t Ch Area F f <br /> Grout Inspection By /� .�,.Q„ ,� Date Z Final Inspection By_ (� Date <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 /> Z i . ,( /r~z/�.: - S R# a t C <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 />