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it <br /> FILE COP <br /> M San Joaquin County <br /> Environmental Health Department E or, SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 195202 MITIGATION <br /> (209) 468-3449 Fax: (209) 468-3433 Web: www.sjgowoPg/ehd,i, r ' 1 7H UNIT 11/ <br /> iL <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 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 appllcation 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 Locstlon I �Uf� lIl, ��I r- ,�Ofoh5i croaastreet ITayrlienerlAlu city .5kck zip `l5aleU Assessrsd 713 Sd <br /> PROPERTY 'V d I ' " ill ! hNSt B �! 8r� WafuC rfry�ie 1 <br /> Owner J <br /> p n Address /' dig . f. Ci Zip -✓� hora>,A' -rJi >� - <br /> C-57 Contractor I�SZ' jU, �ilLl „�e}r,- AldIdddm's�s,ZOO N . s'�, 5+. c;rylr/o I ZIpy57 /Ifi Lic#Ooz33'I Phone#y.� -Gb A �zyzy <br /> Consultant / Sub CntrSIRAAUS CyII/ifuy,mfwttuj ,Addresa 33o Camyon PU( Dr� <br /> ltz.Leudl &M4 Mic# 95� 8Z Phana# 530 �G7G -�.dGZ <br /> GIS Coordinates: X , Y , Township Range Section <br /> W7QRK TO BE PERF D: <br /> NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING # g OVER-BORE. DIAMETER <br /> WELL # /11 W-I iI /oJf]dJ}�i OrZ2Z3 OPRESSURE GROUT <br /> 0 `Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING A�OLLOW t� <br /> yy ,, STEM DIA. OF BOREHOLE <br /> p," jL' , 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 5J '44) TYPE OF CASING: 0 STEEL X6VC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALIJ - SI.� ` TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br /> 0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: $Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS [ILL4 Cfontrv} <br /> 0 OTHER: n OTHER APPROX. BORING DEPTH SO r-lU0 ` 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> COMMENTS: <br /> CONDUCTOR CASING PROPOSED /lrc (d YES, list specifications In comment section) <br /> - <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS, <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS, <br /> 1 hereby certify that 1 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, C f / <br /> Signedx _ 54 `(( 64y`h Tite/Company p• G , +7 7877 J'//g,/y/S FNV1rra,vm/n/�/ -T"ef <br /> j Print Name_ �(�7-r l71'/`yl ✓' Dale {�J 1 - 1 �1 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS :_ 716 w E /n10Tao4o <br /> WORK PLAN DATED':: n/I /S J714 7 <br /> Application Accepted By / � t ryC..L,.A Date Issued U <br /> Area <br /> Grout Inspection Byl d�6 ,v+.: r t _Date SSI 14 (o �- cic�i Inspection 3 f� I'` - ate /t7 - / <br /> --sem-r�--. .. ._. <br /> Destruction Inspection By Dale -" <br /> COMMENTS / CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT ! SERVICE REQUEST # INVOICE <br /> 3SD l $ 1 f ?31 1336 SR# 3159/ <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 />