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,o " n Joaquin County ( tw y <br /> y•. <br /> 2 Environmental Health Department :: ;�rv„f=r.17 SITE <br /> w Ftt C <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 IVEMITIGATION <br /> (209) 468-3449 Fax: (209)468-3433 Web: www.sjgov.org/eh�UP4 2 7 7006 UNIT IV <br /> o- <br /> Well Permit Application SANJO,rtQ ,r; <br /> ENVIRONMENTAL <br /> COUNTY <br /> • NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEEIEALTH DEPARTMENT <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 /> O <br /> WELL Location/ PP 3EfiT SI. Cross Street L11,V2� ,OF City S7acx-T1 Zip Assessors <br /> / Fic. arcel# IS- -020 -09 <br /> F <br /> PROPERTY ' } <br /> Owner FAM jlEZ� T00.JSAddress /S33 E- L/ND1AJ Aw`Citysru.,arpd Zip 9 S-Phone#(Ze2) 9"-'SY'lot, <br /> t r— <br /> C•57 Contractor cSPceAW w. E1CPLo0.AarlAddress,?3lu1r W%yoA. la. City fflrcmJ Zip 95YoS Lic# SPhone#C4ellr S- 5}f�- <br /> Consultant/Sub Cntr 1 1izl rAC.-. Address 2-WS-e. w.YaTLtF sr City n!o ,J Lilt Phone#C?,ani 24E-134S- <br /> GIS Coordinates:X 'Y Township Range Section - <br /> WORK TO BE PERFORMED:. t I +/ <br /> 0 NEW WELL/BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER*) DESTRUCTION (choose type below) <br /> 0 SOIL BORING# - 0 OVER-BORE. DIAMETER <br /> 0 WELL# RESSURE GROUT 1 <br /> *Other L I <br /> r GROUT SPECIFICATIONS Cahw.31T <br /> COMMENTS: l Sn.ierwA or 3 nc. emo-A ---s, LA101-015 -}s RAW Ou -46 -, waw Dfs <br /> e <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS f <br /> Q MONITORING 0 HOLLOW STEM DIA:OF BOREHOLE_ a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:------ <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: 111! <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: p AUGERS 0 HOSE <br /> a 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 /> O OTHER:_0 OTHER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 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. I <br /> 48 WORKING HOURS NOTIOE REQUIRED FOR INSPECTIONS. J: <br /> I hereby certif t t I h e e ed this application and that the wbrk will be done in accordance with San Joaquin <br /> County Or es, ule Regulations, and all applicable California State Laws. <br /> Signed x Title/Company 15TAW PwJO+WAE1L <br /> Pdnt Name C!J4Z15 �El�o�.1,aP-- Date (Ole,/O(1 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: //b <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued - 35 , Are <br /> Grout Inspection By - Date - Final Inspection By -AAA '-"'ate o <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> P FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT;SERVICE REQUEST# INVOICE <br /> Z9ov SR# 4 X393 <br /> _ /WC_-WAIVER_ C-57 Letter of Authorization to sigryRmit Encroachment doc 7✓i� <br /> EHD 29-02-001 A!/ f VV <br /> 6/22/04 A16 <br /> thp f .. e <br />