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1 �- <br /> San Joaquin County <br /> °z Environmental 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 /> Ck Well Permit Application 200 OCT 19 AM 10: ' � <br /> s <br /> N -REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE fS gf5',/+0 IJ I ,( C 0y'P4 T Y 'Yn •1�- � <br /> V a'o <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work d �c �' #' jj��� ��m� ade in compliance with San Z <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Envtronmenta tmtttf� ff Q <br /> W Assessors <br /> Location rrw,/ "ssStreet City t i" / oy <br /> Zip Parcel# <br /> PROPR 1 <br /> OwNit^ " k � � '{ GD <br /> �Address City Zipf5 -Phone# ���tQ� 3 <br /> ner <br /> C-57 Contractor Address �I2� ( u�-� 4�� City_1 �f4'SJiar '�Istione# S2 5�3�3 Samoa <br /> Consultant/Sub Cntr Address [!X1 �FO(�cs $�City,sLic# one# (70) 3C/ <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERF D: <br /> EW WELL/ CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> SOIL BO G# PTS 13 . 12- 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0*Other r GROUT SPECIFICATIONS / <br /> COMMENTS: ITMC 0,Qr <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS rv/ <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE.?n, MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: _ _Q <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL—t e-Cw ' TREMIE TYPE TO BE USED: AUGERS HOSE <br /> 0 AIR SPARGE/OZONE PUSH POINT(GP o PT ROUT SEAL PUMPED: s 0 No (N�1OTFMAXIrPM FREE-FA L DEPTH IS 30') <br /> OIL BORING p HAND AUGER GROUT SPECIFICATIONS -_,r t kt�r� 11 <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 1 *—l(Ja 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> Gf (� COND CTOR CASING PROPOSED (if NAS,list specifications in com ent section) , <br /> COMMENTS: CIIj r l,� <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 Ordinances Rules andR gulations, an II a licable California State Laws. <br /> Signed T' any �G -`t'�' <br /> Date�� Q <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 620 Wes t- Com'ha r+er- WaV <br /> WORK PLAN DATED/: A U Qy s +- 3t . 2 oo S <br /> Application Accepted By y i e.♦-e r i,aL, AG_�*Z'A_r+-n eGf Date Issued /0 -/ 9- 0s- Areae <br /> Grout Inspection By ytcY1! L. m!'J9,,djjn!±:7 Date /G-3(--01— Final Inspection By c toL.�2A1�G{r�6zx ate /aS— <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3Sb 16 /d SR# 00±±4-5-0 <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 />