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F1man Joaquin County <br /> Envirbfinental Health Department `''r SITE <br /> 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 /> 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,Chapter 9-1115.3 and the Standards ofjS/_an,LJoaquin County Environmental Health Department. <br /> WELL Location 3535 E. �1ejol�Ee- Cross Street [V(tlltfJtt City c� G �D Zip SeParcel# rs <br /> PROPERTY p �L <br /> Owner(��TRIrL;ui��ioJcU,jtoy�, Address la NyAAtijRC- t� City Ay�,�}ocir, Zip x{'150 Phone# K5) 1ST{ZG5`5 <br /> f+ -�" 1 L S <br /> C-57 Contractor \�r� t�A S ilut f+rAddress %0 t%1n W— r,�—city�eZ Zip 7553 Lic# (PJ(P�b1 Phone# CgZ5,�(3-r7 Q <br /> Consultant/Sub Cntr�� (tiN b P6VirCuwt�� j Address '637 cj�oLw VA City S (. Lic# Phone# [j0q)467—jD(7!n <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/ BORING (CYT, EOPROBE,HYDR ER") 0 DESTRUCTION (choose type below) <br /> SOIL BORING# ZS�. �tefs. tae-lt � IJ V 0 OVER-BORE. DIAMETER <br /> \440 ELL# 0 PRESSURE GROUT <br /> "Other MAP 2 R 2006 GROUT SPECIFICATIONS <br /> COM ME TS: <br /> TYPE OF WELL INSTALLATION TYPE C0NSTRFJQW&AO 961161FRTIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE Z 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 l d' TREMIE TYPE TO BE USED: `%AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE PUSH POINT(GP o CPT GROUT SEAL PUMPED: 0 Yes ;;No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS -Ha-I l <br /> 0 OTHER:_0 OTHER APPROX. BORING DEPTH— 1101 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 /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. QQ J <br /> Signed x �ti f Title/Company sv, �/ Geon 1-14 1j ,+-)11t&eA c�eQEi{�;{�UIILtCtc�tyi f <br /> Print Name Date 0;J-23--O(o <br /> DEPARTMENT USE ONLY <br /> ".� <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �S>f — �—C�� <� 3So3 <br /> WORK PLAN DATED: F 6 O � <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By V Date Final Inspection By to <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# F <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> So) 21-7 9 3 23 � )/2s <br /> S R# ��z <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 />