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COPYo San Joaquin County <br /> Environmental Health Department (DN 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 ApplicatioQ QV AM 16 F11 2ifill <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM RAj9jSAVr; <br /> Application is hereby made to San Joaquin County for a permit to construct and/or Install the work`4w",64 i <br /> ftrn made 1n compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin Count *k nt. <br /> WELLLocationZ�S CN-�, C11, �I'Vd. Cross Street R � Ax, C S�k>^ Zi °I�lu Assessors <br /> �_ rt � ity R ' � Parcel# (OdK <br /> PROPERTY <br /> Owner US A PQ W t'kr torp, Address 101 d 1 Ali euw► �-�,�S��t1UCIty9'6UM Wk Zip 113 d 1 Phoppne��# <br /> C-57 Contractor ke$gi,^ t Sa�Pc T*}�I AddressZZo N. ��� S�. CityyWad &j Zip9�77GLic#0"1;3�Phone# <br /> Consultant I Sub Cntr Address 3330 6'%�, No bry- Citcftww Lic# Phone# <br /> SCS <br /> ,,✓✓ �,�y� <br /> GIS Coordinates:415 : Township i N Range ` Section <br /> WORK TO BE PERFORMED: <br /> )(NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> O0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> IKWELL#_Mw'11 0 PRESSURE GROUT <br /> 0.Other • GROUT SPECIFICATIONy� <br /> COMMENTS: 2P X-5&/ <br /> TYPE OF WELL I CATION TYPE C C CIFI S NIS rOn` � IL 19 <br /> Jvf�` 1�%ice , <br /> MONITORING a HOLLOW STEM DIA.OF BOREH _ 9 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING D 4 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNE 0 TYPE OF CASING: 0 STEEL $'PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL G TREMIE TYPE TO BE USED: 0 AUGERS k,HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes YNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUG RGROUT SPECIFICATIONS g&MI AN t-14"-` <br /> 0 OTHER: OTHER ti APPROX.BORING DEPTH 16' OOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> A' C NDt�CTOR CASING�PROPOS O (if YEJ5,list specifications in comment sedlon) <br /> COMMENTS: 111A L� /VD LFq•O Z /�/L� QD ""� 7� �R� , <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/Q'" in s, Rules and Regulations,and all applicable California State Laws. <br /> ne <br /> Sigd Tltle/Com'any <br /> Print Name 4stut '6%44 j Date -7 <br /> DEPARTMENT USE ONLY/D <br /> SITE MAP IN UNIT IV FILE,ADDRESS: - Z Z <br /> WORK PLAN DATED: IV D �-• <br /> Application Accepted By Date Issuedy' Z •� Area'' <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# RE 'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 5D / SR# 3 <br /> C-57 WC_-WAIVER_ C-57 Letter of Authorization to sign permit- Encroachment docAR <br /> EHD 29-02-001 <br /> FILE <br /> C <br /> 6/22/04 <br />