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,a kinJoaggin County • FILE COPY <br /> r ° Environmental Health Department SITE <br /> a ' 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 /> {r 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 Count e,�menf Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Loca on Zt'u6eti WV Cross Street b'Arcy Qk ity Lu,* f' Zip 95330 Parcel# <br /> PROPERTY I{..I of <br /> Owner Q.ycr 25/avrds/ Address 73 WW�64eWa l RJ City�Zip7f360Phone# <br /> C-57 Contractor tt�." Address P6 l3oK LII b CityTb/,eL Zip 9576NILic#7.1<% Oc Phone# (171b) 777-r71 cU <br /> Consultant I Sub Cntr G06E0 1 rK, Address A00 tJ-,Twey 13/„kity -rMcy Lic# Phone od% 16 0600 <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 /> O SOIL BORING# DOVER-BORE. DIAMETER <br /> 'WELL# 03 R W— _ 0 PRESSURE GROUT <br /> O'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS >4 It <br /> $JOONITORING HOLLOW STEM DIA.OF BOREHOLE <br /> � , 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:_ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSgch 40 TYPE OF CASING: 0 STEEL XPVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Tle,9,- C¢.w%tvt <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 39. 0 BOLTED TRAFFIC BOX or STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Ru an Regulations,and all applicable California State Laws. <br /> Signed x GTTitle/Company J 6 NT <br /> Print Name 7."C- � "' Cj/ Date 9 �� 0� RECEIVED <br /> DEPARTMENT USE ONLY SEP 2 6 2005 <br /> SITE MAP IN UNIT IV FILE, ADDR SS: �O �� 6� <br /> WORK PLAN DATED: Q SAN JOAOUIN COANTY <br /> 9 n / MENT <br /> Application Accepted By Date Issued !/W Area <br /> tNv <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SER4doc <br /> INVOICE <br /> Zg� a �$'l Do -I-7lfLf o SR# <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroach <br /> EHD 29-02-001 <br /> 6/22/04 <br />