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ut -,an Joaquin County <br /> Environmental Health Department 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 /> L,FOR 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 350SA)ayy bCIVL Cross Street IAtuoito I4.City 15 �4vK Zip 45"Z03 Parcel# t62"030-03 <br /> PROPERTY 'te t� t�"`"� <br /> Owneri?o Ipro pj, ( LC/ Address `d C `f D _CityzV4t�_L.A5-4/Vn'Wgy5 11Phone# - <br /> C-57 ContractorRSL cDri <br /> q I' Address?-20 At. Ea0-Sired CityW961114 & ZipIg"776Lic*W2 Phone#S30-66, -Z-4 V <br /> Consultant/Sub Cntr Lpr}k —f C 6,L4 • AddressL9S R,Wr oa k.S f City tSO0&1, ic#F011 99 Phone#NOS-232-2%00 <br /> e al p <br /> GIS Coordinates:X 3� 5� 00 Y I21 �0! 30"—,Township 1 1- N Range II E Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT-,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# p 0 OVER-BORE. DIAMETER <br /> V�NELL# IP- - -�1 8 LC 9 Pff)-� 0 PRESSURE GROUT <br /> 0"Other i GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING HOLLOW STEM DIA.OF BOREHOLE S 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: Z <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS Sck. 40 TYPE OF CASING: 0 STEEL eVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 3o' TREMIE TYPE TO BE USED: VAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONSIVEP� ?01AAA CV"4,A1, 3-S'?+ Btn4On,'tL %w 4r <br /> I(OTHER:0, 1, B OTHER APPROX.BORING DEPTH SO' BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED AM (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 Ord' ncU., ZU.IeLand Regulations, and all applicable California State Laws. rr <br /> Signed x j� - / Titie/Company x5k /HAMA L( } f Gtola is'+' 'f1` TEA IYLC. <br /> Print Name JAYS vl cur —Date-4/5--ho <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,AD RESS: <br /> WORK PLAN DATED: GG <br /> Application Accepted By Date Issued Z3/O 7 Area (� 7 <br /> Grout Inspection By Date G D? Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: W e-' <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHEC�K# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> P`jDI `1 " 8�" 1 r to tk— 3 +l sR# USD-32-7 <br /> C-57 WC_WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />