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San Joaquin County <br /> EJJnmental Health DepartmenP ' SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> 4� <br /> 4,­ <br /> 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 describeNEWir. <br /> �ie �r,�mpliance with San <br /> Joaquin County Development Title,Chapter 8-1115.3 and the Standards of San Joaquin County EnvironmeA <br /> ARTNf rs <br /> WELL Location f W aAktj a 5� Cross Street N 6ct� City`I rbwlpN Zip 9 -Z0_,L Parcel#1'39 fes <br /> PROP _ ,t <br /> Owner rAcm �(>w�, f 7 Add pss-SM S _ SI TZ AVE City �tae.K'rQd ZiLR5" Phone#�• 4" —'04 <br /> C-57Contractor_SPec-f ormEKPIor`u'4dd`ress 501sSherednamP14CtySang;e�Zip9/ ZzLic#S/2zl. Phone# <br /> Consultant 1 Sub Cntr dress. .(-t tLf "i✓it _Zjif^ 1 <br /> L�'r�"r� j���ct� R .� y � '� Lim Thane# K"e <br /> GIS Colo dfes X LE'-13ip3 T, Y ZIr1 I ALL(7 Township Z N Range �� Section <br /> ` WORK TO BE PERFORMED: <br /> Q NEW WELL 1 BORING (CPT, GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER") q DESTRUCTION (choose type below) <br /> SOIL BORING# <br /> 0 OVER-BORE;. DIAMETER <br /> WELL# I FIE COPY <br /> a PRESSURE GROUT <br /> 11'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 'r <br /> If MONITORING HOLLOW STEM DIA.OF BOREHOLE iD" 0 MULTIPLE CASINGS. O MULTI-LEVEL WELL CASING DIA; `I it_ <br /> 0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS� �TYPE OF CASING: a STEEL a PVC a OTHER: <br /> a VAPOR 9 MUD ROTARY DEPTH OF GROUT SEAL iTREMIE TYPE TO BE USED: AUGERS <br /> � p HOSE' <br /> a AIR SPARGE/OZONE, 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes I No (NOPE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> o SOIL BORING O HAND AUGER GROUT SPECIFICATIONS fJ -T C �11s[dAii S 'S I <br /> la OTHER: a OTHER APPROX.BORING DEPTH y S` BOLTED TRAFFIC BOX or [I STOVE PIPE <br /> CONDUCTOR CASING PROPOSED. (if YES,list specifications in comment section) <br /> COMMENTS:7R A r�t0_ F20V, t11 LL'13[; I~LY- il Wall GR C>t W� ;5Ck zi`ANI=- <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 /> CouO nances, Ru n Regulatio , and all.applicable California State Laws. <br /> sign Title/Compan <br /> Print Name d n�s - Date U <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ` 3.0 ha rl n cS+y-e_e <br /> WORK PLAN DATED:_ Ma,�L_J 2- 00 (, <br /> Application Accepted By f_ e Date Issued k 20 d Area. )4s-9 <br /> Grout Inspection By _ lti*;knA anc,_Date c.L Final Inspection By CtSArda_ Date O <br /> Destruction Inspection By Date <br /> . COMMENTS/CONDITIONS.— _ + e <br /> ACCOUNTING ONLY: AID# F <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3Sw 8q 5r <br /> o 3 3174.00 SR# 40 3 8 <br /> C-57^ WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br /> EHD 29-02-001 . <br /> 6122/04 <br />