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Iftan Joaquin County <br /> FILE L`O� H <br /> 4 % Environmental Health Wpartment SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> c `' YoR��P Well Permit Application ZOp6�AR Pr <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DAtQ1jS UED, <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the w ;d } i ,44 <br /> tia b[i� i�made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County ifohorfe�tt�r ,iaart ent. <br /> ` Tr�9 Assessors <br /> WELL Location y��1� Cross Street _ City'Tc-ac.� zip 9 5 6 Parcel# <br /> PROPERTY 54 .nda-d pac tsft#1955- <br /> Ownero�- +J- CepAddress 387,5 Hoc�r-d pct. City2IecsQr, Iron Zip 945W8 Phone# <br /> C-57 Contractor\/*W Dcii1;meq Address P•O- 6ok LlIG Cityj.5!e Zip g56yl Lic# L00C/ Phone#04)?77- 106 <br /> Consultant/Sub Cntr EA)(,F_-6 j nc. Address X0 A)fccy BAId. City Lic# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) ' DESTRUCTION (choose type below) <br /> 0 SOIL BORING# ,COVER-BORE. DIAMETER <br /> 0 WELL# []PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS ] <br /> COMMENTS: fFban�w� M-an; I o vL, �Cl� c t d�n. `a CenuC'A <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> $MONITORING 0,HOLLOW STEM DIA.OF BOREHOLE S 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: []AUGERS []HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> i <br /> CONDUCTOR CASING PROPOSED (if 1YES,list specifications in comment section) <br /> COMMENTS: lJ; ✓Ior �NObI�^ YU `�� Cavi vv�iy�rn Pyt I-P5-1 <br /> WC[IS r-'15 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby ertif that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County rdi n s, R and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company T� LO T-R Ci <br /> f �/z(�0 & <br /> Print Nam (n-U Date <br /> DEPARTMENT USE ONLY e q <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �/irQ�6f�711 F L�NF7X -+- 5' Fer ,t <br /> WORK PLAN DATED: 3 -1706 <br /> Application Accepted ByA Date Issued Area <br /> Grout Inspection By Date Final Inspection By e <br /> Destruction Inspection By Date �i <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# i FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> X62 Q, G 3 SR# <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment docAIR <br /> EHD 29-02-001 <br /> 6/22/04 <br />