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, <br /> x* „f; <br /> CO <br /> San Joaquin County R <br /> Environmental Health Department <br /> nti "`"'�' ` 1:. 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> { <br /> (209)468-3449 Fax: (209)468-3433 Web: www:sjgov,org/ehd SEP 20f IT IV <br /> Well Permit Application ENVIRONME - <br /> rH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE'ISSUED �� M��/ ERVICES <br /> Application is hereby made to San Joaquin County for a permit to construct and/or instal[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 73,> Sf-.&•ec& Crass Street /y Cs►"cty f City 51'0cky-a.-r Zip 61—Z3Z. Parcel# <br /> PROPE5T1' <br /> Owner r ,sron-j ��/rell'�r CAddress 817 S. Cc,s7 r City 51ocKfiarr Zip'?fZ-6 Phone#(Ro6'(6b <br /> C-57 Contractor w W t>, r Address Iaa !`;�Fh Orfs--I City ����K Zip�r Yl Lic# o90 Phone#(9/195777^�1f�v <br /> �t3� rG•-a..k w�rrc�G �] <br /> Consultant I Su b Cntr CoHdeY Address fcr..r- -r- City ff� Phone# �2Tr/--XT8 ` <br /> GIS Coordinates:X _.Y Township Range Section O\\_ <br /> WORK TO BE PERFORMED: <br /> )(NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH HAND-AUGER,OTHER") p DESTRUCTION (choose type below) m <br /> 0 SOIL BORING# 0 OVER-BORE=. DIAME=TER <br /> )(WELL#. 3 0 PRESSURE GROUT <br /> 0"Other GROUT SPECIFICATIONS <br /> COMMENTS:-f0vtae.-Leel we✓LC�14c1;pled �ti ✓die:+<sr 7 syC�fiCl��/!�<._LPl4f7rr+�1rf�.l� r�(4-! da ft�l 1/y <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE �" []MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA; <br /> 0 EXTRACTION 0 AIR HAMMERfDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL JYPVC (]OTHER: <br /> D VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL 3p TREMIE TYPE TO BE USED: 9 AUGERS 0 HOSE J <br /> j]AIR SPARGE)OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: I(Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 11 SOIL BORING a HANE]AUGER GROUT SPECIFICATIONS Noor C_ e✓!t e,1 f— _ <br /> 0 OTHER:_ - fl OTHER APPROX.BORING DEPTH S`L> / 0BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (too (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 Ordi ances EZUIes and Regulations,and all applicable California State Laws. <br /> Signed x Title/Company c: �GGc /J r_/Ca 701 <br /> Print Name e r 0 Date_- <br /> DEPARTMENT USE ONLY . <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 130 _ECES' p n n ej_S__fre-e __ 9+0e (!A <br /> WORK PLAN DATED: AUa,{xt _ ) C 2 o6 !j _ �1 <br /> Application Accepted By j J C 1/�. t Date Issued_ aSe A 1t 17' 6r J4. x,004Area_..J4 S� V UZ <br /> Grout Inspection By } Date_41- 214•0 Inspection By DCAFYIDate__ <br /> Destruction Inspection By Date <br /> COMMENTS l CONDITIONS: lyls±d IhAW - <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> 3501 11r$?.00 81.00 SR#- da 3gGo l <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 />