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J ut GC� � C [] � CCG� <br /> o � � San Joaquin Count;' <br /> AR pIvironmental Health Department SITE <br /> 30 ast Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> VlRONt( T4 $if Fax: (209) 468-3433 Web : www. sjgov.org/ehd UNIT IV <br /> PERMIT/SERVICES <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES I 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 /> Assessors <br /> WELL Location 2\ 0 -3 i�o,.,�xd,-- Cross Street !- �c�L\ . n City �-oCkko� Zip `iS ZO4 Parcel# \ -L <br /> PROPERTY <br /> Owner Address 'Y> 35w •, nA \-w�e.� city � ot; .>< � zip Phone# <br /> �-�� <br /> C-57 Contractor (.--c�.sc, 0 � Address 3`v '�37L , . city -. ,. zip l5ly2f-ic#'jpjS , Phone# hip b3k - nb l <br /> � r - �1 <br /> Consultant / Sub Cntr Ae.C.FDpS � R3Ia . Addressw4lo kc% Pww��i S� akAo Lic# l <br /> Phone# NO ps 0Nzf A � �� <br /> ILA, S �\e <br /> GIS Coordinates: Township Range Section <br /> WORK TO BE PERFORMED: <br /> (NEW WELL / BORING (CPT­i, OP�ROB HYDROPUNCH, HAND-AUGER, OTHER*) p DESTRUCTION (choose type below) <br /> 0 SOIL BORING # p OVER-BORE. DIAMETER <br /> 0 WELL #_ _ _ _Q(j 0 PRESSURE GROUT <br /> T*Other ur t GROUT SPECIFICATIONS <br /> V' - p . Sv - -L SV - 3 SV - y Sy - ' ` <br /> COMMENTS: S <br /> r r � Gy ..� Sv --1 L v - `t , S � - S S c: \ t�r p <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 1" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS_ TYPE OF CASING: p STEEL p PVC 0 OTHER: <br /> `VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL._ TREMIE TYPE TO BE USED: 0 AUGERS n HOSE <br /> 0 AIR SPARGE/ OZONE $ PUSH POINT GP r CPT)GROUT SEAL PUMPED: a Yes %tNo (NOTE : MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS ( a mp� l t --W) <br /> 0 OTHER 0 OTHER APPROX. BORING DEPTH 1 ' 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 State Laws . <br /> Signed x Titie/Company p 'c0 S - 1 ..- <br /> Print Name T C7 \c\�v� G. �Y\�a_.�S Date <br /> DEPARTMENT USE ONLY �� p u <br /> SITE MAP IN UNIT IV FILE, ADDRESS : okb — 6�// 16 <br /> WORK PLAN DATED: 6 - 5a d do c4plcwc a <br /> Application Accepted By. Date Issued 4 Area <br /> Grout Inspection By Date Final Inspection By - e b 'b <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # p REC'D BY DATE PERMIT I SERVICE REQUEST # INVOICE <br /> 350 VM 89 Q �� ° 5 3 ✓� D SR 0 9 <br /> WC=WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />