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pan Joaquin county <br /> Envii+tmental Health Department* SITE <br /> w 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 /> Ir-0a <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 <br /> 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location � Assessors <br /> go V`I -(AAAr kyr w0.H Cross Street KG0 N City��Zip�TS306 Parcel# 6 -0 30-03 <br /> Owwnne!Ta�Lt <tntln j 1 Address '11 S Sk PfI Loew D✓ City V& c zip S G Phone# <br /> C£7 Contractor Q(W ttCl v4 �Nr'L Address '.ZG M• Rst- .S+• Ci�ZipjSVIL Lic#goZj'�l Phone#7 0-G68'1�Y2'y <br /> Consultant/Sub Cntr(.Atrt o- <br /> 16Q AddressaT POdknµS St. City-sl ncxa(o0.Lic# Phone#?07- 13S-48"-�u <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROSE,HYDROPUNCH,HAIL-Al1� l ) 0 DESTRUCTION (choose type below) <br /> a SOIL BORING# �` [L U` 0 OVER-BORE. DIAMETER <br /> FFWELL# ` a PRESSURE GROUT <br /> 44•Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �J 11 <br /> ONITORING a HOLLOW STEM DIA.OF BOREHOLE 11 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: -T <br /> j EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS0 TYPE OF CASING: ()STEEL PVC 11 OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAbbL 1 oL r TREMIE TYPE TO BE USED: D AUGERS HOSE <br /> n AIR SPARGE/OZONE a PUSH POINT(GP or COT)GROUT SEAL PUMPED: 7Qes No (NOTE: MAXIMUM FREE-FALL DEPTH IS.30') <br /> 1]SOIL BORING a HAND AUGER GROUT SPECIFICATIONS 0gr-HA rd 1 <br /> /11 <br /> 0 OTHER: OTHERM6 CON 1'G APPROX.BORING DEPTH Or 11W `OOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED Vl0 (if YES,list specifications In comment section) <br /> 2 <br /> COMMENTS:�'R7LA'I� 1tiil5�llr .rnt n 'M" mb�, V v•l.d rDlt�-P� lliSTO(rQc�'I.tYx,�r.V- W1lAS,}- _I.�-P <br /> cotpt-t,(,trfD4 , <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 SaiNJoaquin <br /> County Ordin es, Rules an R gulations, and all applicable California State Laws. SetAiof �tn c* C'le0(0 t ro <br /> Signedx Title/Company aAALViJ E. &\JtvJvtw <br /> \ �. � ' <br /> Print Name ,P�1�1 Date -1—. <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: L4 t'I r) (' iACA V j-e V- 1A20\ hoc�C 4oc <br /> WORK PLAN DATED: I—i 1�Tl <br /> Application Accepted By Date Issued Area 7, <br /> Grout Inspection By I �."". Date 10 I`( 0S Final Inspection By an.�oh Date lv'i}'o S- <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> Ill r FROM - <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3S01 X661 g 1,00 zol- 3 q tvy o5 SR# �q [9 <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 />