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a� <br /> A° '"..� 2 San Joaquid County FILE COPY <br /> 1\0Environmental Health Department SITE <br /> { 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 MITIGATION <br /> s- (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> UNIT IV <br /> <'rFaR 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 com lance with San <br /> Joaquin County Development Title,Chapter 9-11/115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> �4y0 W B64NNcr AVE Assessors <br /> WELL Location r9NNPr ?VF, Cross Street Fda iv O City j.'o; Zip 9S2ySparcel# Os5^320—% <br /> PROPRTY •D <br /> cA <br /> r / `15'ZVS / p <br /> Owner E MC Ltt CARPL Address 70o Gg�e CAIvF„Dity�'14 C°/W C�;pq Sbyo Pnone# /(� Y ^g o6 7 <br /> n ASC l R9�cho <br /> MM <br /> C-57 ContractorCA5CA0 rr)I'n( Address363Z QrtC C1i fie. City Cn Con..A Zip�7 yZLic#7/�$TO phone# Ib <br /> Consultant I Sub Cntr A.G. E. Address957 SkOK/ AO CitySra(Kr� Lic# 22 Phone95 V 7/oob <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) B DESTRUCTION (choose type below) <br /> 'a SOIL BORING# It a OVER-BORE. DIAMETER <br /> -AQwELL# M W—40 L —r-£�r11 �?/ 0PRESSURE GROUT <br /> a*Other ( C.�� GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFIC NS <br /> MONITORING '(10LLOW STEM DIA.OF BOREHOLE1lZ� MULTIPLE CASIN 0 MULTI-LEVEL WELL CASING DIA: Z2'�_ <br /> B EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESSS P . 0 TYPE OF CASING: B STEEL , PVC BOTHER: <br /> 0 VAPOR - p MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: )(AUGERS p HOSE <br /> a AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: b <br /> 0HAND AUGER GROUT SPECIFICATIONSIIII Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING ParTLAN -rL <br /> D 7—YpC � <br /> ()OTHER:_0 OTHER APPROX.BORING DEPTH 5' � .�t'BOLTED TRAFFIC BOX or a STOVE PIPE <br /> /� CONqqyCTOR cj rt`� P POSED VP (if YES,list specifications in comment section) <br /> COMMENTS: 5ZL Acnro�'D UV() 'W n/ N c'�fl�v n1 4ft ZooN <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 Re ulations, and all applicable California Laws. <br /> Signed �_ Title/Company //5 tJip( i lTf'o%C) Sj <br /> Print NameIcDate ,) own <br /> DEPARTMENT USE ONLY p \ <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 6�2 ( ' C Z7.g C.Upe�lNQQ./.3 — Cf"IUS- <br /> WORK PLAN DATED: O <br /> Application Accepted By Date Issued <br /> Area <br /> Grout Inspection By Date Final Inspection ate <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAG# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 2Q-q w !0 SR# D Dad <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encr Went doc ✓ 1 r <br /> EHD 29-02-001 h S6"--A 4Ln_ � <br /> 1 <br /> 6/22/04 - Du <br />