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Can Joaquin County <br /> yEnvirbr mental Health Departme&/,- - ,. <br /> { 304 East Weber Avenue, 3rd Floor, Stockton, <br /> �,q6202` 520QS MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web.www.sj"'�4/ UNIT P � � y UNIT IV <br /> 'poR�'� Well Permit Application /,,r��i ts[Ty <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 of San Joaquin County Environmental Health Department. <br /> n Assessors <br /> WELL Location_3 536 E, C n �Rd Cross Street l�al City fl Zip ',SUS Parcel# <br /> PROPER <br /> Owner 'C2Ct`��,4ivtp Address '300D e. "``j{- CitytAjnritn Zip 5D Phone# 425 -154'205& <br /> C-57 Contractor8 ttJAA�t'' J D60 i►� Address _RCD�Hry <br /> Ate ArdeMu-e. Citrek.A ZipCLSSo3 Lic#�IZZ 11 Phone#t-10.6)44t-YO1j V <br /> D <br /> Consultant/Sub Cntr Nd G&6W701lMt"dress %3'1 Ski gal City_SjpC�Lic# 01, Phone# (Zl' )1107-LDQ� <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> >>NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> WELL# 'L 0 PRESSURE GROUT <br /> 0*Other T 7 GROUT SPECIFICATIONS <br /> 077 ? : „ <br /> COMMENTS: , <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> }MONITORING )<HOLLOW STEM DIA.OF BOREHOLE_r 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: Z` <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SL►,yo TYPE OF CASING: 0 STEEL )r_PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Sr TREMIE TYPE TO BE USED: 0 AUGERS W, OSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 'des 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 96r44 my LA <br /> 0 OTHER:_a OTHER APPROX.BORING DEPTH I05�� `10' 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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed rz k ,� Title/Company -A_ tbbQLc/ uJ_Qlr!� irGblWtQt+t�l �biL. <br /> Print Name_ G�A f e. v9— Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 3535 �. �C.ee.� r *4;;' LOP <br /> WORK PLAN DATED-: 20 MAY 05 p b �{� <br /> Application Accepted By Date Issued O Z'/ 5 Area Q 6('7' <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 5c3 i 36S 2213 ( _Z5 sR# �� 3 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment docs <br /> EHD 29-02-001 <br /> 6/22/04 <br />