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yoasul � n Joaquin County t <br /> Envir6 ..mentalHealthDepartment 0119 SLE TE <br /> tt 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> � UNIT IV <br /> (209) 468-3449 Fax: (209) 468-3433 Web: www,sjgo . <br /> *••�u, Via * �� 1 � 1� � <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSOABP LG06 <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 Couppty Env�{ �f1�1344th ID �irlt. <br /> ( r lµ - � nCkd3Hl�y i CRMIT/i~ pR 4 Assessors <br /> WELL Location '20 �(g-'K-y Cross Street �p it �7uC r fi� Parcel# lq�-I t20Pr <br /> PROPER jj�� t� <br /> Owner O�Lt'� /7KC1Ci•Ll�$ Address. j'yi/e #d✓nl(d b-C City `�Ck �n Zip4520`( Phone# 3-�j� s } -• 'C/jyj <br /> C-57 Contractor�iP 4 II /V •7t�t�MddYYres//s � ` /�ULUC �Onr.( CityAl Chef. Zip`('r1,i53 Lic# A CV i+hon Z 1 'go0 <br /> Consultant / Sub Cntrr yanimDCa�� Ut%tildtu t,'t@i Address 634 Shaw RA CityLit[ irk Lic# / EL-t Phone# a lQ - Loin <br /> GIS Coordinates: X , Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> JNEW WELL / BORING ((PT, EOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) D DESTRUCTION (choose type below) <br /> /C % SOIL BORING # aw a OVER-BORE. DIAMETER <br /> D WELL # 0 PRESSURE GROUT <br /> n *Other GROUT SPECIFICATIONS <br /> COMMENTS: id-hid a •' r{ t� S G7a.PEY sgfn les <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING D HOLLOW STEM DIA. OF BOREHOLE' 0 MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA <br /> a EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESSAIJA� TYPE OF CASING: D STEEL D PVC D OTHER: OH60SE D VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL hf6tj TREMIE TYPE TO BE USED: n AUGERS <br /> 0 AIR SPARGE/ OZONE XPUSH POINT (GP o CPT GROUT SEAL PUMPED: )(Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONSd •}tt e T1$ <br /> D <br /> OTHER:.0 OTHER APPROX. BORING DEPTH :ZSO� D BOLTED TRAFFIC BOX or D 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 cern that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ord! nces , Rules and Regulations, and all applicable California State Laws ,Laws , ) <br /> Signed x � i/[^ . v - Title/Company/UTft til U. s ctjir -f R, r <br /> Print Name /171YY1_ �e/7YY%leS' Date - ��l9 /1) 1R <br /> DEPARTMENT USE ONLY ,D <br /> SITE MAP IN UNIT IV FILE, ADDRESS : Jam / 5- o'� 1 <br /> WORK PLAN DATED : Z - Z�0 - ofo <br /> Application Accepted By Date Issued YZ'111 —0 Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS / CONDITIONS : <br /> ACCOUNTING ONLY: AID# F ` <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # R C'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> 3� 3 SR# D g <br /> C- -vim WC - WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />