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� r <br /> San Joaquin Con `` 22 20 <br /> r . .. 9 tY <br /> Environmental Health Department SITE <br /> zf: 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> „. (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehdIII <br /> 1 :. It V <br /> Well Permit Application <br /> .. .. ...... ..... <br /> NON-REFUNDABLE PERMIT EXPIRES 7 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 /> �-Lcatlo�3 toss Street A�tiWELsY. City bC3CTp zip!95202-Parcel# 14A— <br /> PROPS <br /> Owner-C-4 f }1/�Address 92J FI"Zarc.dn City sllo� Zip 9S202. �a9 (j,37 8`(-11 <br /> C-57 Contractor _Address 349 S��`Rl t3E Ci tyl��� aicf �Phone#�2A?)772- ,M <br /> Consultant I Sub Cntr6A46VsQ- 6*Q7w7.CAI7L7[Address City J Lic# Phone# 2 <br /> atArfa T <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> / BORING (CPT,GEOPROBE,6ROPUNCH HAND-AUGER,OTHER") D DESTRUCTION (choose type below) <br /> OIL BORING# -, ._.?D—35 0 OVER-BORE. DIAMETER <br /> a WELL# 0 PRESSURE GROUT <br /> 0"Other GROUT SPECIFICATIONS <br /> COMMENTS t 1bA)1" O <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA,OF BOREHOLE'"?-'t 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION IR HAMMER/DRIVEN CASING THICKNESSAVATYPE OF CASING: D STEEL 0 PVC D OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS &HC�EjP <br /> D AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED,: es D No {NOTE: MAXIMUM FREE-FALL DEPTH IS 301, <br /> / `SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS T',W 1217-AM rr—FeA61UT GoNGJ rG- C-/A)1S64 <br /> �L ]�THERA a OTHER APPROX.BORING DEPTH r 0 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 certify that I have prepared th' application and that the work will be done in accordance with San Joaquin <br /> County Ordin es, Rules and Re rations,and all applicable California State Laws. �r- <br /> Signedx Title/Company� llJIC+a1S7- C�/t1�olL�ilat7' TiuscClEgfil� <br /> Print Name Date Zz <br /> DEPARTMENT USE ONLY L <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 3 4Sf a e- Q 131 o J( f 6 Cq'gf St <br /> WORK PLAN DATED: Ztv -2006 <br /> Application Aecepted,�B/ye t rf Date Issued Area i 4,q <br /> Grout Inspection By _4 Date_9- _-D� Final Inspection By ivate 9 7•dts <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: e P I - Z r n GYd ri <br /> oSf'PE <br /> ACCOUNTING ONLY: AIQtI FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3503 295�Gn 374, 60 SR# 06 7 g4`� <br /> C-57 WC=WAIVER C-57 Letter of Authorization to sign permit,.`Encroachment doc <br /> E14D 29-02-001 ' <br /> 6122/04 <br /> a <br />