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*San Joaquin County <br /> Environmental Health Department <br /> SITE <br /> 600 E.Main Street,Stockton,CA 95202-3029 rj�;-; ,MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.drg/ehd ,:9L--Il % — = UNIT IV <br /> C-aC/FORN`P Well Permit Application �'- j 200 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUBD i Tri <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described: This applicationIsJhatle In compliance witr'San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environ/mental Health Departme�sessors <br /> WELL Locat]on `/Cross Street city �- <br /> c�taQVt�V lL �5v✓) LV Ci Jt�Kf � zip Parcel# �J <br /> < <br /> 1 J q /40 <br /> PROPERTY . 7 LLL City �.ir1)17E1 j5IZLPhoneIOS3 t,l' 3$s7 <br /> Owner C C S �- Address <br /> yet Avl Itis wlt� l %4So� 63� 58') bai' � )/-�t9 <br /> C-57 Contractor f re G.5- �' Ste• ('^ Address ) 0 X __City ZIP Lie# Phone# <br /> U c' 4�5f r,,: n2f'rc" :�� one# 74�• Si"�-Q/�� 3 <br /> Consultant I Sub Cntr 'T"5/7 �OG` Q 5 Address x Clty Lw# I <br /> Al_?. <br /> l24 C f , [�[ shi � �/V RangeC) X71 �y Section5?�.1 <br /> — <br /> GIS Coordinates:X <br /> WO EPR J � V 1zI I,1 ('Ur')i)S3j lpDESTRUCTION (choose type below) <br /> EW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) <br /> OILBORING# OOVEBORE. DIAMETER <br /> WELL# 0 PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> 0"Other <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONST UCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA OF BOREHOLE•` t U MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:, <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: (1 STEEL 0 PVC 0 OTHER: <br /> a VAPOR a MUD ROTARY ,tt� DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br /> p A R SPARGE/OZONE .tPUSH POINT(GP o7GPT)GROUT SEAL PUMPED: 0 Yes o (NOTE: MAXIMUM FREE7FALt71DEPTH IS 30') <br /> SOIL BORING `HAND AUGER GROUT SPECIFICATIONS <br /> A Y'6i �t <br /> p OTHER: OTHER APPROX.BORING DEPTH _T [ —0 BOLTED TRAFFIC BO or STOVE P PE <br /> (7P lrbo z CONDUCTOR CASING PROPOSED A/I, (if YES,list specifications in comment section) <br /> b, -�#•Frli�� r f0 N.'I` 5 ( r.o. r' <br /> c' 4 – bfi'\4n'+c01 Ce.lte�v <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 p epared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Ru► s n7ions, and 11 applicable California State Laws. <br /> ,si E e l��Q�I AP e r f Cs -�ssr x c.Signed xTitlelCompany�Print Name <br /> Date 1 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: t Z l l' l� n rt ' r L✓a+�F <br /> WORK PLAN DATED: <br /> Date Issued 4;' <br /> o� 7�Area 'Cb L <br /> Application Accepted By 1 Date <br /> Grout Inspection By 'Date �l i t4 v1 Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: - <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> S �t:? I JD3'3 ti30-�- SR# (7L? 5-1t0II,/-� <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc_ <br /> EHD 29.02-001web <br /> 6122/04 <br />