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USan Joaquin County ))r, <br /> Environmental Health Department G1 r L _ " ;;SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 95202pp MITIGA'T'ION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/ehgCT 1 5 2004 UNIT IV <br /> PO 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 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. 1 <br /> Assessors <br /> WELL Location 19S0 E. t1We2 Avg, Cross Street A Soy . City S4ux kkoy\ Zip OIS7i4 Parcel# IS$- 050-06 <br /> PROPSF�TY �1bwn•••0•!{4�`vt <br /> Owner It( D.( 1p'cIt o Address-`(51r kA'Urc+kIL. City S6-L� Zip19Z%7 Phone# Zoq- 97?-921Z ` <br /> C <br /> C-57 ContractorVironGklTnc. Address al\O /\d o.ms eve City San Laan4roZip4YV7Lic#,oS527 Phone# S10-57676 I <br /> Consultant/Sub Cntr�Cer%mn Address_13 BQC.-r S;• A7-33 City S rr Lic# Phone*'1"tS-3SI-ZYoo <br /> GIS Coordinates:X 37.458 7`3`r•-IV <br /> Township — Range Section — <br /> WORK TO BE PERFORMED: <br /> t <br /> NEW WELL/BORING (CPT,G OPROBE YDROPUNCH,HAND-AUGER,OTHER`) 1 DESTRUCTION (choose type below) <br /> 11 SOIL BORING* I 0 OVER-BORE. DIAMETER <br /> WELL# 0 PRESSURE GROUT / L <br /> O'Other GROUT SPECIFICATIONS etea(' cRmeNl �. <br /> COMMENTS: - <br /> i <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS '/ <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLES" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS MIX TYPE OF CASING: 0 STEEL D PVC BOTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Olt+ TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE I PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 01No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> e SOIL BORING [I HAND AUGER GROUT SPECIFICATIONS n¢o.E' cgs c t¢ - Cr' Gr ckc..(S ll <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH ISr-Zo' 0 BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR QASING PROPOSED_ tJ0 (if YES,list specifications in comment section) <br /> COMMENTS: no c.siva ��\1� 'j''q 1012.6�Oy <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. #h <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 <br /> Land <br /> =R/�s'gulations, and all applicable California State Laws. <br /> Signed x l J�� W r r U\` -a Title/Company CAvsroA vv e-. -.1 D f I? M s,,,,�/7e rru cu,.v <br /> n�1 l <br /> Print Name �o cS.,>✓` Date Ipf1-(j0`( <br /> DEPARTMENT U$E ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 7�I `]SO E %✓(�tic/L <br /> WORK PLAN DATED: /y/ C! <br /> Application Accepted By 'r- ' °� _Date Issued C"-/�� - �' Y Area <br /> Grout Inspection By Date 1" A Final Inspection By • ag�� Date_LI14& S <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: 11-e- ka I ttYe--t AIol <br /> ACCOUNTING ONLY: AID# F <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# 1d <br /> INVOICE <br /> `� -3 I IL/77 l `A'1 /D / Git/ SR# Yo 1 <br /> C-57 WCWAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ r <br /> WC— <br /> -WAIVER_ <br /> 29-02-001 - <br /> 6/22/04 <br />