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San Joaquin County <br /> Environmental Health Department �i SITE <br /> a 600 E.Main Street, Stockton,CA 95202-3029 SEP 18 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjg16t#, dd 100/ UNIT IV <br /> `1 0 Well Permit Application ERM�U1lTjs f , '41. <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED V7CF§ <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 /> u Assessors <br /> WELL Location J 10 S, (:e,4c fAyt k Cross Street d1VrrA%$4. City 5+,cp� ZipjS203 Parcel# 14q_076 <br /> _10I <br /> PROPE TY CPG$ E) 14138 n <br /> Owner�ae res+Ebner Cc.Address3y�, Son ,,,e, Citya 9m 00o tl Zip4KT3 Phone# (qdS)866' SSo$ <br /> C-57ContractorO mCll�Si� Sn�Address I-oy Essex 1-rve Cky Zip�49'01 Lilt L'�,Ls'Q'}Phone#�S�o�a3'1-4575- <br /> ons <br /> Cultant Sub Cntr oKrC Q2PAC Cc_ oTAddress (`)90 N. C8ah�o- -111_ity Wd^eviA Lic# � Phone# (9aS)QIS-y6o <br /> Sul '3a <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> IEWWELL/BORING (CPT G OPROB YDROPUNCH ND-AUG OTHER-) aDESTRUCTION (choose type below) <br /> OIL BORING# 12 a OVER-BORE. DIAMETER <br /> a WELL# a PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: 7[Q!tr \ 'h.,a , j- IQ �.nc �� �tecd�it�tel .Sem e� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE_ a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: _ <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC a OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS a HOSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> .SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER: )OTHER Sae 06oV-- APPROX.BORING DEPTH a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in co ment section) <br /> COMMENTS: I�aoK.h%I �o C rdIA- .�.� `�a.1e.:r Gc�o��1- .v ✓aA— CR...e.{- �i�o.. .4.�.1 eIL.�+ - <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 Ordina/r/js, Rul s a d Regulations, and all applicable California State Laws. <br /> Signed x �r�� , Titl Compan \aCt�.c- GCO. <br /> Print Name 'S CAAU4i L- Cscvlas Date O aI I I LII m-1 <br /> DEPARTMENT USE ONLY �" <br /> SITE MAP IN UNIT IV FILE,ATESS:� 5-t0 5 Cg^d\•-t-! e ` - 5�--,u '�- <br /> WORK PLAN DATED: ki „rte <br /> Application Accepted By Date Issued L O-A' Area 5 <br /> Grout Inspection By Date Final Inspection I 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 /> Lao l 8+ ✓' 8 a, 00 ('I 3o gjzt joj SR# o o s10 A)­ <br /> C-57 V/' WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD 29-02-001 web <br /> 6/22/04 <br />