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i • <br /> #*U-1 �an Joaquin County <br /> Environmental Health Department SITE <br /> 600 E.Main Street, Stockton,CA 95202-3029 MITIGATION <br /> (209)468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> Well Permit Application <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 Deve//II�op nt Ti�1llfel�,.�Chapter 9--1111�1,5j.3 and the Standards of San Joaquin County Environmental Health Department. �I <br /> WELL Location IIOC� U'WI f0 ( 06e,Cross Street �k �iT. City �O�( Zip -/ Yo Parcel#rN;'m -0113 <br /> PROPERTY / p ((�� <br /> Owner C5- //�� II Address` o gay 1910 City LO Ziog5- Phone# 333 YS6� <br /> C-57 Contractor GS 0l"AW Address Zk5A jDfl'tPC. ( �rCte,City KacNG� Zip-/57i4LLic#1�1/0 Phone o4�61 V �&/ <br /> Consultant/Sub Cntr !'T Address (32,7 SVS -City5+ Phone# <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) '14ESTRUCTION (choose type below) <br /> 0 SOIL BORING# `OVER-BORE. DIAMETER 1S" <br /> 0 WELL# j&ESSURE GROUT <br /> 0`Other GROUT SPECIFICATIONS q la/6 <br /> COMMENTS: 0Lxr--- 0t'I1U-O S AAW - I MUS"CI /Ii W"S3 d MW '/Y &SSSy(e Cf-a&c(II o-!,Iet-5 6 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS V• <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_ 0 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: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (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 Ordinaq�es, Rules and egulations, and all applicable California <br /> DState <br /> _Laws. 1 f�� <br /> Signedx L�/L Title/Company 1 FOl'c�i l`a/'t0'C b'eV�� T 1 6, <br /> Print Name D( icy. /N, /ha.i Daef- �-d/D <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: J& S' e P2 <br /> WORK PLAN DATED: !O <br /> / 2 a✓t�G <br /> Application Accepted By t-d�/GFaB-�-C Date Issued<hi&o Area 992 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By ( Date <br /> e <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 05OZ 60- (00' 3/l 7.0 �J-X 5'/I3 /o SR# 00579,�S0 <br /> C-57_ WC---WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> E-]D 29-02-001web <br /> 6/22/04 <br />