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'i a" ' oo )an Joaquin County FILE VOP Y <br /> M Q 04 Environmental Health Department SITE <br /> y t 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 /> p <br /> ' � aR Well Permit Application p C A � <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM� TE"ISSCJ r `1 2: `g2 O r V <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the "K deAri¢0'6hig, p�' iF is made in compliance with San <br /> Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County �fjyiY,vrj(7jepil lg,�JlFkl apartment. 1 u <br /> 10 15 WeJ ( Mar r UI N vq D H �L T EP A R 7M� f� p(� ParcelAssessors l r 1 _Z7Jp_ 1,l <br /> WELL Location '^'7 Cross Streety lJr City �J �' oOG �r"" 1) Zip . Parcel# bbl V <br /> PROPERTY hhL f, f <br /> Owner NGC, Emmet heA PT- Address PO Box 15 City City OLI V\ Zipphone# �� � ' "16 'J � � o � 3 <br /> t !, n Rct"mac w— q ,��" 6 <br /> C-57 Contractor IQS-'yhtt�leykc - �.. Address � l -15cc �U VU Y1q �1�� ,,I(, City (t: rt(OVcf�' f Zip ' 15� ZLic#$I'78YS' Ph i -- 5041 <br /> Consultant / Sub CntrAA y 1�IuA Geo �Vlyl (onn tress SD S tt(,y,�0 i<-PX City �TOG�TGn Lic# 683ZZ7 Phone# ).69 - 40— 1 Ub 6 <br /> GIS Coordinates: X , y , Township Range Section <br /> WORK TO BE PERFORMED: <br /> % NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) p DESTRUCTION (choose type below) <br /> 0 SOIL BORING # 0 OVER-BORE. DIAMETER <br /> 0 WELL # I a I2— 0 PRESSURE GROUT <br /> p *Other „ / GROUT SPECIFICATIONS <br /> COMMENTS: y <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> I MONITORING HOLLOW STEM DIA. OF BOREHOLE . b � 0 MULTIPLE CASINGS p MULTI-LEVEL WELL CASING DIA <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS Sby, TYPE OF CASING: 0 STEEL JfPVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 5I ( } TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br /> 0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT) GROUT SEAL PUMPED: 0 Yes d No (NOTE : MAXIMUM FREE-FALL DEPTH IS 30 ') <br /> T- <br /> 0 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS I l;Ic a/�l pOYE"IUNA <br /> 0 OTHER:.0 OTHER APPROX. BORING DEPTH l00 T ' BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NO (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 Ordinances , R sand Rens, and all applicable California State Laws . <br /> Signed x_ Title/Company A4VVAce'& <br /> Print Name r- ' Date 5 y3 0 �� 6 <br /> DEPARTMENT USE ONLY42/ <br /> SITE MAP IN UNIT IV FILE, ADDRESS : S Clcamc <br /> WORK PLAN DATED : D <br /> Application Accepted By " / Date Issued IO ^ 49 60 Area <br /> Grout Inspection By D4 Final Inspection By Date <br /> Destruction Inspection By Date <br /> i <br /> COMMENTS / CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED C.H, EEC # REC'D BY DATE PERMIT I SERVICE REQUEST # INVOICE <br /> u <br /> SR# Q� tG � <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 />