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#r:0j';i) <br /> C LEQUED 4Ran Joaquin Coi{nty'1 • �•�� �O• • <br /> Environmental Health Department SITE <br /> AR 1 & 2OEast Weber Avenue,3rd Floor, Stockton,CA 95202 MITIGATION <br /> RONMEWWE`�L"449 Fax:(209)468-3433 Web:www.sjgov.org/ehd UNIT IV <br /> RMIPSERVICES Well Permit Application 11 n� <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 applicat is n <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location 1901 lr.). CYIa-F�.2Y" tit Cross StreetG-fe yo A\4- city S�Oc.K}ov� Zip 95ROb Parcel# ItO�J -0�0 -11 <br /> PROPERTY nn ` <br /> Owner A[ravn� �kJ (61PAddress 3(A �114trt Oo�,J �BIVd.Citylllq 41a IISZip 14303 Phone# <br /> C-57 Contractor Address City Zip LickPhone# <br /> Consultant/Sub Cntr Ge oym,l.''.)k CgM:g±j , Address 2T`lLl MAtn 54 Cityeo Lic# Phone#(559) -74r-1 - a5-35 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ,ANEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> XSOIL BORING# 5 a OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> U MONITORING n HOLLOW STEM DIA.OF BOREHOLE 3 a MULTIPLE CASINGS n MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: O STEEL p PVC p OTHER: <br /> II VAPOR a MUD ROTARY DEPTH OF GROUT SEAL__ _ TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE U PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING tHAND AUGER GROUT SPECIFICATIONSSetcE°rli <br /> a OTHER: OTHER APPROX.BORING DEPTH 5.5' n BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED S,list specifications in comment section) <br /> COMMENTS: Soy <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify Riat I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordin"T S, Rules gulations and-all applicable California State Laws.! <br /> Signe Title/Company C7?6µ'I'i 'o` <br /> Print Name 1 ��InrK"1 Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: lgb ' " eVR-411 <br /> WORK PLAN DATED: Z �` Ct�c <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date <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 /> SR# oo yl <br /> C-57n WC C✓ -WAIVER_ C-57 Lett r of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />