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pan Joaquin county <br /> Envifilmental Health Department • 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 /> 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 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 /> WELL Location 414 W1• VNaI✓�/ Via rL (� Q Assessors I/ 03C)O <br /> "1 Cross Street �µCO N City �Dth� Zip J San6 Parcel# bJ J <br /> PROPERTTYy __ 11 -7 /� <br /> Owner 1=dWA+ d1/Cr AddressPo�1X �� 1 .1, CitylF <br /> (�A Cd ip%eA31 Phonne# <br /> C-57 Contractor 9e�a.nI- Coni c_ Address aao 1J. NASI- �t- CCityt-4 Zip9S77GLi/cI#0p2'33 <br /> Consultant/Sub Cntr CA18ALJW KVi A 5%W • Address 7•�IO QLY S JitI -CitySOKftW10. Lic#9S-t76 Phone#q-`t35-4f9$U <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> WELL#Z FILE COPY 0 PRESSURE GROUT <br /> D Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS (� <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 1 f t <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS O TYPE OF CASING: 0 STEEL )rPVC 0 OTHER: <br /> g VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL I06 1 TREMIE TYPE TO BE USED: p AUGERS 10SE <br /> 0 AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: jVes tNo "(NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS q ,,6(i4 k' I I <br /> 0 OTHER:�r OTHER i L APPROX.BORING DEPTH r 17.0 I BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED y\ o (if YES,list specifications in comment section) <br /> COMMENTS: C <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinal es, RuleseanndDRe'gulations, and all applicable Californian State Laws. <br /> Signed x 7�%1%/�^Wt�t�V Title/Company 6A �Y1 0 BA VM"1 SSL. <br /> Print Name _Vo Q'e'elt-r Date q ter- 10s: <br /> DEPARTMENT USE ONLY n/ 1 — <br /> SITE MAP IN UNIT IV FILE,ADDRESS: `l`{0 ('k0'A4-'g' tA t, <br /> WORK PLAN DATED: I k `) T ) �y <br /> Application Accepted By [A Date Issued Area 621,9 <br /> Grout Inspection By Date 4LZL5l Final Inspection By Date_Iy/i/ DS-" <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: rill <br /> ACCOUNTING ONLY: AID# FAC# <br /> L <br /> CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> SU1 �6 °l $q.n0 ZvI�Z I�Y os" SR# q' f <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 />