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10San Joaquin County • _ <br /> Environmental Health Depart 612(C'F ED SITE <br /> 600 E. Main Street, Stockton,CA 95202-3029` MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 web: www.sjgovbWektd 8 ZOG7 UNIT IV <br /> 9Z <br /> ,NIP rF°R Well Permit Application ENVIRONMENT HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE §"dy�BDT/SERVICES <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 /> �1 t Assessors <br /> WELL Location a�yyOJ E_ Imc� Cross Street ESca14,^ city ` rl. zip 9Sd30 Parcel# 092- loo-os <br /> PROPERTY as .. <br /> Owner Paor r GAS 4 E 4�ro. Address 3 00& m�City S+nS.rr a Zip9f�Phone#69a98b6-S-Sty, <br /> /� oorn 1-113$ <br /> C-57 Contractor r.i"e a (I�Address IQSt1Frjp> Alt . City-kuk,,"ZiP9L&I_Lic#047s"Phone# (51c�a37^u/S7s <br /> 1910 N•Cal1Toria$I <br /> Consultant Sub CntrTi�.w,(?a.- coir-o, Address Su}je, g-, 'city4r-!�ic# '�- Phone# (`t2TjaL5-V_Lj <br /> GIS Coordinates:X �� ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: GEOPROB <br /> EW WELL I BORING fCPT YDROPUNCH, AND-AUGE OTHER`) O DESTRUCTION (choose type below) <br /> SOIL BORING# [ D OVER-BORE. DIAMETER <br /> WELL# aPRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: $cv' h c <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING D HOLLOW STEM DIA.OF BOREHOLE_ D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL D PVC D OTHER: <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS D HOSE <br /> D AIR SPARGE/OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED: D Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING D HAND AUGER GROUT SPECIFICATIONS <br /> D OTHER: —XOTHER Se¢ At> g— APPROX.BORING DEPTH D BOLTED TRAFFIC BOX or D STOVE PIPE <br /> `1 /CnONDUCTOR CASING PROPOSED (if YES,list specifications in\comment section) <br /> COMMENTS:�gLA\1 Te C C154 T e- Ur-{S.o.. 4-4�1 <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 Ordinan es, Rululles ad/Regulations, and all applicable California State Laws. <br /> Signedx �5�- Title ompany 'rte,--rm Pr(`A¢�[ L,j-NL'✓ <br /> Print Name ��g�„��. L Dale nil)L/�Qo 7 <br /> DEPARTMENT USE ONLY I <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 2 1400 C- (-L.� Vlira l I-c.vt-S+i1K t-wt <br /> WORK PLAN DATED: S,n�r_1c� Z'OD1 <br /> Application Accepted By Date Area L Il <br /> t <br /> —oraotirrrr+speetioBy -- <br /> Destruction Inspection By Date <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 /> ,MCFN VI. 91-&( SR#005204 <br /> C-57 V WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 web <br /> 6/22/04 <br />