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i <br /> San Joaquin County FILE COPY <br /> a <br /> 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.sjgoI / hd 5 31 �U UNIT IV <br /> Well Permit Application 2�U6 � " <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATL51 rl �' i f1Ui i+SL �O AL <br /> t ( � GG <br /> RTP, <br /> Application is hereby made to San Joaquin County for a permit to construct and/or Install the work det(e1LThis�9pplteation is made in compliance with San <br /> Joaquin County Development Title, Chapter 0-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> � � y 7 $ rL DarAoo S � • FL /fin/fjOD e Assessors <br /> WELLLocation _ CrossStreet . 4 % CityS70 (. Kr,. Zip $9 lob parcel# ! 75 / 2003 <br /> PROPERTY "`�'r.� K S, £: L <br /> Owner GALTFOW Pr LII5 AddressI . Pf/ 00 City SToc1(T9 \ Zipc7ST04 Phone# Zo `1 LIB 6 355y <br /> C•57 Contractor Ts r 4M C t lrc uD „R PAit ress Iii $ Lv RAniulo 2 <br /> G y�� OQ• �y C Po ip 95'742 Lic#. �$1ssYg Phone# 916 (isJ — SS by <br /> Consultant / Sub Cntr Q G , r Address_ 2 3 7 .SNA IA/ City STnr III Lic# 6-d 0 Z Z 7 Phone# Z o ) b / 996 <br /> GIS Coordinates: X., Y., Township Range Section <br /> WORK TO BE PERFORMED: <br /> B NEW WELL / BORING. (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') DESTRUCTION (choose type tt}}elo <br /> 9SOIL BORING # VER-BORE. DIAMETER / O r <br /> 0 WELL # "`���TT�"''' ly <br /> a *Other n RESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: SFE 4 TT A 04,FO W u AKII AIJ J I <br /> TYPE OF WELL `IN/S'TALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MQ�t <br /> r / <br /> ONITORING OLLOW STEM DIA. OF BOREHOLE a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS Sc. it00 JC TYPE OF CASING: 0 STEELVC E OTHER: <br /> D VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 30 ' TREMIE TYPE TO BE UbEb: ,GAUGERS 0 HOSE <br /> a AIR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: ea E No (NOTE : MAXIMUM F jEE-FALL DEPTH IS 30') <br /> a SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS o ( T A 0 716 <br /> n OTHER:.H OTHER APPROX. BORING DEPTH ,S.S a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <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 Sate Laws, <br /> Signed x 7iVlr1A— Title/Company ` Rpt <br /> Print Name C V r d dag Date <br /> DEPARTMENT USE ONLY <br /> SI-T AAFIN-UNITIV-FIL�ADDRESS:--IA= �� n Orct f ree <br /> WORK PLAN DATED :_t U 1 44 45- 20 0 (a <br /> Application Accepted By V i c-f'e e i a L. M e Date Issued_ JULY Lc 2 D 0 G Area � s <br /> Grout Inspection ey Date 7FInaI Inspection By 54 r., .¢ Date <br /> Destruction Inspection By VkI Mct'I Date 7 � Z0 - 0 <br /> COMMENTS / CONDITIONS: i <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> 2. <br /> 3503 27 33900 SR# <br /> Ua473a7 <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 />