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op4•I <br /> CIO San COPY <br /> ` Joaquin County <br /> N_. :? 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.sigov.org/ehd <br /> Well Permit Application UNIT IV <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDApplD'v <br /> Joaquin Coin 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 /> WELL Location 'L\05 Cross StreetF�cv,�,�r Cit Assessors <br /> WA Parcel#_ 1 <br /> PROPERTY 2.3 OF OL`j <br /> Owner �, $ ; Address 'SSS S W'i r„a Vim. Cg pr <br /> 55�� Y�-4�r . Zip cQA$—�/a�/�,'�Phone# ! p. <br /> C-57 Contractor C E Address ��L Q Rty�iP .q# 1 ,7��one 6 �� <br /> Consultant/Sub Cntr ?SU, Address 1 0 old -�—/"' f` 8'p <br /> I -it <br /> City ' Lie# Phone# \lb) ifFS-=1 <br /> GIS Coordinates:X lmCz;lv��1� li-d <br /> Y ,Township Range Section <br /> WORK TO BE PERFORMED <br /> KNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) p DESTRUCTION (choose type below) <br /> 0 SOIL BORING#_ I(µ� �.V ^_I� <br /> AWELL# (�- O DOVER-BORE. DIAMETER <br /> O'Ofher _p �n�.��11 �,-,r 3 0 PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: C..\�N�2ca a we iv P. _ Ai- <br /> TYPE <br /> OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE_ ,'MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL ' PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: XAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: n OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: y,�;n. L-\A N2• R_ -fir s1 c.,-. r V g. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed GW�—� n-,;. Title/Company i;�W�..S} S <br /> Print Name SCO-Y�.nS M� Date Co I �2.1,p` p'� <br /> DEPARTMENT USE ONLY /J ,� �/ <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 09.D 7z ($un.�Grs (UwR J— <br /> WORK PLAN DATED: - -Oro <br /> Application Accepted By /eC_ n Mob <br /> Grout Inspection By ate Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> WACCOUNTINGAID# FAC# <br /> AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE1REQUEST# INVOICE <br /> ( � sRIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc F� <br /> EHD 29-02-001 <br /> 6/22/04 <br />