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�oPaU.IN. San Joaquin County I I( I­- , <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202; ci, MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> -S F-IL-);"i"%, <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 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 /> Assessors <br /> WELL Location Cross Street 6-1111S+e&t City Zip Parcel# <br /> PROPERTY� -33 '360 <br /> Owner 'co'- Mooy?, Address C-;4611 E 5hs&f .-Cit baln-k Zip ':�9 , 6hone4 2GI-926--;- <br /> /f& X <br /> C-57 Contracto .4aldinA-644,1Address 41DWC- citya(li(W-T- Zip]4%'J Lic4VQKT Phone/G <br /> V _77b6tV Phone# <br /> Consultant/Sub Cn r f�%V"J&Address 112-44- 80�W11a City �' Lic# <br /> GIS Coordinates:X <br /> ly Township Range Section <br /> WORK TO BE PERFORMED: <br /> "EW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> ASOIL BORING# CPT-2- a OVER-BORE. DIAMETER <br /> a WELL# a PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE 2'l a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA:------ <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC 0 OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS -K.HOSE <br /> a AIR SPARGE/OZONE WUSH POINT(GP or CPT)GROUT SEAL PUMPED: )KYes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> XSOIL BORING a HAND AUGER GROUT SPECIFICATIONS 'l-LA41ra- '91, Qjwe-V-,-{- <br /> a OTHER: a OTHER APPROX.BORING DEPTH '9 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED_ (if YES,list specifications in comment section) <br /> COMMENTS: <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 State Laws. <br /> Signed x Title/Company 5t?k Gno (/CI 11YC�,Z-lc <br /> Print Name ON)C-)a� Date- <br /> j DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By-' 10,eil Date Issued 12511Z Area <br /> Grout Inspection By &0/" Date , ,V--Final Inspection By C —Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK 9 REC'D BY DATE PERMIT SERVICE REQUEST# INVOICE <br /> 9(" <br /> 35� 3 &VT/ SR# 00 44q 57 9 <br /> C-57— WC=WAIVER_ C-57 Letter of Authorization to sign permit—Encroachment doc_ <br /> fil�o A, <br /> EHD 29-02-001 ,Jt -35o 5 e-�5,d <br /> 6/22/04 <br />