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,o q�1 �a San Joaquin County <br /> ` Env*,.onmental Health Department,.r SITE <br /> tl1 { <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 We : www.sjgov.org/ehd <br /> P bUNIT IV <br /> gL�FORN` Well Permit Application Q <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 2005 JUL ZS QM $: 07 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is mp in pl' with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Heatph C � <br /> WELL Location s I1U►eik S+-.- Cross Street 5. 10 y tM t �l L. City <br /> PROPERTY <br /> Owner EQ61Qt& C f?) 1,vir. Address 11 131eL Ota- A CityAcm—OCNT Zip DI WS Phone# <br /> C-57 Contractor &MCed C-a-v,V• Address `6'�7 S1411-0Cit S <br /> Jq� nn11 y {�7� Zip , 7�(ti Lic# 9 7 <br /> '� Phone# 447-160y <br /> Consultant/Sub Cntr Aiyettted �eo CHV Address 122 City J Lic# r�Phone# A 77 12,01. <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> `,SOIL BORING# � + 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLEJ.5" 0 MULTIPLE CASINGS <br /> 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS Xh4 TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL + TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE,%ZUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes $-No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 5 -44-41 A <br /> 0 OTHER:_g OTHER APPROX.BORING DEPTH 2-12" 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 /> 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 <br /> �State Laws. <br /> Signed x19 tt�_ 1� r\`�ts�-- Title/Company_�st0.� �QD�D�ti1�ltC1ViWQC4� �Qt�t�dlVb n <br /> Print Name e- lt� L: 1�-1 S'�� Date 7-2,Z--c-5 <br /> ki DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: DC7 <br /> WORK PLAN DATED: -7 1-2- p S <br /> Application Accepted By Date Issued -71�'i/6 5 Area <br /> Grout Inspection By Date u? a 5 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 /> �Ro1 $� aaSs 7�-g ds SR# 433P-`f <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 />