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FILE c <br /> San Joaquin County � I � �r���' SITE <br /> artmen <br /> Environmental Health Dep Mt 0 2004 MITIGATION <br /> 1 304 East Weber Avenue, 3rd Floor, Stockton, C o9 ori/ehd UNIT IV <br /> "•' (209)468-3449 Fax: (209)468-3433 Web: www's�EI�VIRONIJIEi'�I HLNLI <br /> .. , <br /> q. <br /> Well Permit Application PERMIT/SERVICES <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED application is made in compliance with San <br /> for a permit to construct and/or install the work described. This app artment. <br /> Assessors <br /> Application is hereby made to San Joaquin County parcel# <br /> Joaquin County De o ent Title,Chapter 9-1115.3 and the Standards of San Joaquin County�`��tal He eng Zip e 2�� <br /> 151 Cross Street�• '^� 'l <br /> WELL Location o py- S�5 �?O'1 <br /> / Zip�_Phone# 4 <br /> PROPE Address 1 I� �+�'IIUGS+ Dr' _C�ty �"In'17� Phone#9'�G"Y y�°� <br /> Owner C��y���"� /• Zip 7b�Lic# �e <br /> JP. City 124 '�1 <br /> �L t� to( �;pv� Address 33$2 ZSC +4/"��� 0c-11 / Phone# <br /> C-57 Contractor Cit �I't/Icn/-Lic#�� J� <br /> Ee� Address 01'25- 5f 350 — Y�- <br /> I S• Range �o - Section <br /> Consultant/Sub Cntr Township <br /> ,Y <br /> GIS Coordinates:X <br /> DESTRUCTION (choose type below) <br /> WORK TO BE PERFORMED: OVER BORE. DIAMETER <br /> {dEW WELL 1 BORING (CPT,GEOP�OBEHYDIOPUNCH,HAND AUGER,OTHER') PRESSURE GROUT <br /> �;KSOIL BORING# GROUT SPECIFICATIONS — <br /> 0 WELL# <br /> -Other <br /> COMMENTS: <br /> INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS c MULTI-LEVEL WELL CASING DIA: <br /> TYPE OF WELL DIA.OF BOREHOLE U MULTIPL-CASINGS (] PVC 0 OTHER: <br /> �MONITORING �HOLLOW STEM �� TYPE OF CASING: �STEEL 0 <br /> o EXTRACTION o AIR HAM DEPTH <br /> CASING THICKNESS---DEPTH OF GROUT SEAL_?D TREMIE TYPE TO BE USED: �AUGERS x$'30' <br /> VAPOR U MUD ROTARY No NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> USH POIN (GP CPT)GROUT SEAL PUMPED: )qYes ��; f J <br /> AIR SPARGE/OZONE � GROUT SPECIFICATIONS STOVE PIPE <br /> SOIL BORING HAND AUG 0 BOLTED TRAFFIC BOX or <br /> OTHER_ --- APPROX.BORING DEPTH ?d <br /> �OTHER:_ PROPOSED­-0-52 ilf YES,list specifications in comment section) <br /> CONDUCTOR CASING <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENTO PENCROACHMENT <br /> N oNS. <br /> OACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR I <br /> that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> I hereby certify Regulations, and all applicable California State Laws. <br /> County Ord' ances, Rules and Reg Vl <br /> .Title/Company�}-�t I I i� <br /> Signed x Q -17 `/ <br /> Print Name D n r,Q. <br /> DEPARTMENT USEONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: Date issued <br /> Issued <br /> Application Accepted ByDat- <br /> Date Final Inspection <br /> Grout Inspection By Date <br /> Destruction Inspection By <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AIS <br /> FAC# <br /> RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# SR# r)0 3 9 57-Z- <br /> 2 <br /> 7-Z <br /> 24 o I a�$ �1 l �� S•w <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 />