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r� l <br /> an Joaquin County �[��Lr ��ED) <br /> �f y. <br /> EnvirWnmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, C�'9�A26 2006 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: ww ,y*0jd�EA�j UNIT IV <br /> Well Permit Application PE R/'I/T�,SE�VICES TILL to <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED • <br /> f <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 131 S0,4114 Cz-NTM Si g-e- I' Cross Street'WAsH W&TON sr.City `s+0c-KlDe3 Zip CK-2clZ Parcel# 13'730012 <br /> PROPERTY <br /> Owner C r Address 411 i . �L Po A Oc ST City stbc KtD�i Zip g520'L Phone# <br /> /a-/0-orf L'CfJ tri/li`��,- 71G 3632 Drlt6G 411t6t-E RahnGhoG'ar'o6v�� '7l'"1510 <br /> C-57 Contractor �� Add— " Citye�C'��Zip�S- -tic#90tj Phone#t <br /> Consultant/Sub Cntr 13133L Address.10,470 OLD IAAzEt?ML&. O fl,city SAcaArtiEN M Lic# Phone# (q I&)8S4-G 12`/ <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> XNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') Q DESTRUCTION (choose type below) <br /> Q SOIL BORING# Q OVER-BORE. DIAMETER <br /> `A WELL# iv W-ISD2 Q PRESSURE GROUT <br /> Q 'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE ar <br /> Q 7/f Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS 50A-HO TYPE OF CASING: Q STEEL )(PVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEALAPP9424 is 1 ft. TREMIE TYPE TO BE USED: Q AUGERS `HOSE <br /> Q AIR SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: XYes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS S-& SeNia►Jll�- �tiE nT t RC�.tf Nt�kTlyl2l; <br /> OTHER: )(OTHER SoN1c RI f o 1 e� <br /> Q APPROX.BORING DEPTH ItrBOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (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 Ord'nances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x1Ll� Title/Company CA16IfJ6F)Z 1;U 7PA9,yiN6•/931 L <br /> Print Name ViC700, 'E.AaCt}Er" Date 12/1 t/Z066 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 1 3 9 S . Ca.-I-es S-f-r _ _ Sta r-k-6 n. (f,/a' <br /> WORK PLAN DATED: Da+&)ver . 2 00 G <br /> Application Accepted B Y i c-4 o r;a L. Mrs f a r fn e u Date Issued 112. 0 Area 1415 q <br /> Grout Inspection By Date �j-2.9-4`7 Final Inspection By ` }'j Date /1—.24 •b 7 <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: 12.ffdlf /Ylf cl - 19 -D -Z <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3501 89.00 89.00 SR# 004-9279 <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 />