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...man Joaquin County � <br /> � � nv WFL <br /> .ti Environmental Health Departmeyp-R - T <br /> .. < 600 E. Main Street, Stockton, CA 95202-3029 y 1, 2 Z007 MITIGATION <br /> (209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org4i!r <br /> THUNIT IV <br /> ENVIP,ONMENT <br /> Well Permit Application VI RPAiM <br /> L. i►. U ijI <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 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location iia(J iA715� thpv(u f SCI<P Cross Street ifC �V1VP City Zip 9.SP�11,> Parcel# x:33-iS3 i3 <br /> PROPERTY <br /> Owner LMOC.0 Ike(-(bn Address )PW 10M4 �3ey w 7: ,Ye City IY��CLI Zip 1153-1(g i <br /> C-57 Contractor 4r1cAAnrrdRroEnAddress A'17 Ijhnij` Re-'eA City :fi8ti(:Icn ZipQS�)IS Lic# &q.1-1 Phone# D09-rile'!-ILO <br /> Consultant/Sub Cntr Address?)l pilau` f-Z�i8 City : k _Lic#!r$G1^'I Phone# �G�-uU 1-ICCi� <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ;ANEW WELL/ BORING (CPT,GEOROBE,HYDROPUNCH, HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> ,ffSOIL BORING# r�XS-�� Gnd 1b i--SVT 0 OVER-BORE. DIAMETER <br /> 0 WELL# SAW LZ-.21 -07 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 BOREHOLE1,1 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 /> AL -T " <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SE ' C,' TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes -g�No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ,kSOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS -fu x u 'Itis IAONcf L20 OROIP T f <br /> 0 <br /> OTHER:_0 OTHER APPROX. BORING DEPTH S' J-n 6f'bsc 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED N& 0 (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 Ordinances -R les and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company V1(!e IirvSzdei4�iaC11t1iirw( ('Pr t=rH vnz��zz.rzzii, I�1� <br /> Print Name Relb 4- P. Lf Qr _ ` Date <br /> �. DEPARTMENT USE ONLY <br /> I O 1/v;v' I <br /> T <br /> SIE MAP IN UNIT IV FILE,ADDRESS: 2Q <br /> WORK PLAN DATED: = r .I 20C'"7 ZS <br /> Application Accepted By. ( � _}b r I z ` l e f-' Date Issued ) 2 - -2! Area ) S9 <br /> Grout Inspection By '^�'N`�A mPJf�rh Date <br /> 'Q y 'Final Inspection By Date <br /> / <br /> Destruction Inspection By Date <br /> J _ 1 r-1 <br /> COMMENTSICONDITIONS: J�� 'YtC'EYs »� c� �� ' � � ''n(i+ $ -2� �ZI� -Z�1 Qn +�� ��� <br /> ACCOUNTII[; <br /> ONLYID# FAC# <br /> PE CODESMOUNT REMITTED CHECK <br /> S#J RECD BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> � 7G ; ZL t4 40 3 3 �3. 6 G <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 web <br /> 6/22/04 <br />