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FILE COPY <br /> San Joaquin County <br /> Environmental Health Department �itl l � �(, , ; � / 4 )SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209) 468-3449 Fax: (209) 468-3433 Web: www.sigov.org/chd ` ? 1 ,' ,+ i00 / UNIT IV <br /> Well Permit Applicationv . - _r <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 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 /> 7901 b1 90 0(o S �, �// ZI g5a/o Assessora079 350 <br /> WELL Locatlon Cross Street r Evil L]4✓�Q City p Parcel# <br /> PROPER t p , I� 7i-u8 1 ESr( dq< Wado^ err' ti 9 <br /> Owner [ f1 J AddressS-t" � Ci��Zip PhocCn)�e# �J <br /> C47 Contra r 5T, P] I11i AddressZ20 ty , F A s+, City) 00611 Zip q572LUC# M/Z33 Phone#53� 9 -ZVay <br /> 1<400AA ant cr & a n / �� C <br /> consultant / S nV JC ELl on t1uritt "f'Address3 ' �AWIPN✓I I�wC PrCi�ry $5wl Lic# g51od�Z Phone#�( 3U-�70-14 C7 <br /> %'oNq< <br /> GIS Coordinates: X , Y , Townshlp Range Section <br /> WORK TO BE PERFORMED: <br /> 8 NEW WELL I BORING (C T, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) )6ESTRUCTION (choose type below) <br /> O SOIL BORING # �U -BORE. DIAMETER- / 011 4 11 Gi{II CaSivvJ <br /> DWELL # nURE GROUT <br /> IO <br /> 0 .Other / . (60 " ) <br /> G T PECIFICATNS <br /> COMMENTS: O UW — (�( � Ir�t 1, 0l 0 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION 43PECIFICATIONS <br /> 0 MONITORING VOLLOW STEMDIA. BOREHOLE 0 MULTIPLE GS 0 M TI-LEVEL WELL CASING DIA: Y __ <br /> 0 EXTRACTION I � 0 AIR HAMMER/DRIV CASIN QKNES , LIU TY CASING: 0 STEEL )VC O OTHER: <br /> rAPOR epxVt �j ave 0 MUD ROTARY DEP GROU L REMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/ OZONE 0 PUSH POINT (GP Ill SEAL PU D: 0 Yes TE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER G SPEC] TIONS <br /> 0 OTHER: n OTHER OX. 0DE 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> C DUCT ASI P (H YES, list specifications In comment section) <br /> COMMENTS; a <br /> NOTE : OFFSITE BORINGS REQUIRE AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOU OTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that 1 have prepared this Ii n and that the work will be done in accordance with San Joaquin <br /> County Ordinances, R es nd Regulatio a all applicable California State Laws, <br /> Signedx C 1 / Tille]Company I Gam. 7y / / �lY�'u5 I�NVi/Q�lintv✓I'a1^� ,/�cr. <br /> Print Name J 1 iw Date _ <br /> VADEPARTMENT USE ONLY / <br /> SITE MAP IN UNIT IV FILE, ADDRESS : Z / 6 Io ( Sv t C�c�"L� <br /> WORK PLAN DATED: 577 46 7 q <br /> Application Accepted By . / r r}-e.R,e-n Date Issued ?Z910 (7 Areay�,- _ <br /> Grout Inspection By U Date Final Inspection By Date <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 /> 35 k. & a ) 33 0 fire SlS9� <br /> C-57_ WC_-WATVER_ C-57 Letter of Authorization to sign permit_ _ Encroac'-Iment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />