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rias Ran 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 /> �rFoaN` 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 Development Title, hapler 9-1115.3 nd the Standards of San Joaquin County Environmental Health Department. <br /> C Q f , �nel O ito �OrX Asa vO Parcel#Assessors <br /> WELL Location t 1 lf� Cross Slree City 1 Zip <br /> PROPERTY <br /> Owner ( Address, I (.J PAe S city zip 5-)V Phone# <br /> C-57 Contractor P- "f l �� Address �MfC, �1 l% n ity o zip%�Lial'3OJ O Phon 9i6 65 1* <br /> Consultant/Sub CntrIA&� Address o 77 �{�W l(J City_c2i�2 _1-ic#-P2Phone# d� i� " <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') S&DESTRUCTION (choose t e below) <br /> 0 SOIL BORING# 4WVER-BORE. DIAMETER if <br /> 0 WELL# .PRESSURE GROUT <br /> a*Other n / ( GROUTSP CIFICATTIONS V 6 �on5 ✓-fe /J <br /> COMMENTS: Iue IA7"� ui�l 2 0() 'T XrII�PA QI� 0;10 <br /> (-t 4(a/ u-elli $(/1PCrO of <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS Cr <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN 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: 0 AUGERS 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 G <br /> 0 OTHER: R OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE V <br /> J� ' D- fin/ n CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> See-)� /�T� c-A'ep'� UGtG�YS - <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, ules "egulations, and all applicable Californi S_tarte_Laws. n / I _ <br /> Signed x Title/Company �f mil J✓1 wX Geo �OS7�/S�/� <br /> Print Name 6 1 I -n'IQ Date �i J"0/ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Pl_ <br /> WORK PLAN DATED: T�„� 'ir✓YrlD <br /> Application Accepted By Date Issued Oxho Area r' <br /> Grout Inspection By Date Final Inspection BTT 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 /> agoZ (,o- 60, 3///y /aic gl� ,o SR#D059951 <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> 6MI29-02-001 web <br /> 6/22/04 <br />