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0 • FILE COPY <br /> San Joaquin County <br /> y a Environmental Health Department 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 n L D <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �p <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 /> IS 340 (2,1.e,w100s Assessors 198-060" f0 <br /> WELL Location )!T_3490 f^ck-n�" Ave Cross Street 54- City L . j+ Zip 75330 Parcel# 196-064D J7 <br /> PROPERTY Cc�Y <br /> Owner TN Ge.r11Ke.5 Address 11187 S Wity _Zip9S,333C,Phone# (209) -9S6y <br /> C-57Contractor V+W 0orWV15 Address Q•0- 669 1116 City TAItC � Zip9S641Lic#1400nem# Ib — 21100 <br /> Consultant/Sub Cntr PtJ�s 60 int. Address tfl80 N. `15_G" SW Citycat Lic# Phone#(."t0`I� PJ S—Ofa/0 <br /> 5}t >t3 <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> JkNEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> a SOIL BORING# 0 OVER-BORE. DIAMETER <br /> (WELL# ftM4y -H O."d R W!W-S 0 PRESSURE GROUT <br /> a'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS r' <br /> )LMONITORING HOLLOW STEM DIA.OF BOREHOLE 0 r 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS" 40 TYPE OF CASING: 0 STEEL _XPVC B OTHER: <br /> p VAPOR p MUD ROTARY DEPTH OF GROUT SEAL rn:r1. .5 TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> 0 AIR SPARGE]OZONE U PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> U SOIL BORING ll HAND AUGER GROUT SPECIFICATIONS Y,%e � <br /> a OTHER: Q OTHER APPROX.BORING DEPTH 3 Z Q BOLTED TRAFFIC BOX or 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 ndJ2egulations, and all applicable California State Laws. <br /> Signed x _ 1 Title/Company Ent ('L'O .r-q'+t - <br /> Print Name_ c./' 0aW C,-1 Date //yl 105' <br /> DEPARTMENT USE ONLY NZ <br /> SITE MAP IN UNIT IV FILE, ADDRESS: d UU <br /> WORK PLAN DATED: t'� a o <br /> Application Accepted By Date Issued �Ep u <br /> Grout Inspection By Date Final Inspection BynpQ� g1IBE�— <br /> Destruction Inspection By Date EN'"'ftpp0„CNC1PpRTM <br /> N <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> A0 J 1p F-7. nn I 7-" g - , p sR# D D <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 />