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jo M co 41an Joaquin County 40 <br /> i Environmental Health Department SITE <br /> " 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 MITIGATION <br /> P' (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> 9�/FORa, 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 /> WELL Location 250001FNr OC(F-64 - Cross Street 578GK7.ON 57- Ci Assessors <br /> ty L0�( Zip gsZyfO parcelsors y{(O-/S <br /> PROPERTY <br /> Owneri'E715/ZtL/N0A'WlGK Address Z W(v IOA6-6-lo 4(,? cityLj 0 Zip9r2-Y0Phone# <br /> C-57 Contractor V+W DlZttl NGr AddressE.0, gOK 2{llo CitybTON lZipyOYeLic#7to 9e tPhone#qN-93^743s <br /> Consultant/Sub Cntr 4W*5 V5rE4-t5 Address 479r3 WARM SPRIA("City FR ml Lic# Phone#570-353-0320 <br /> GIS Coordinates:X 'Y ,Township Range Section <br /> W RK TO BE PERFORMED: <br /> EW W LL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) a DESTRUCTION (choose type below) <br /> KOIL BORING# 1 S'1 a OVER-BORE. DIAMETER <br /> a WELL# a PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSLLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING OTALLOW STEM OR DIA.OF BOREHOLE!! � 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC a OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS a HOSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> eSOIL BORING n��HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER: yUTHERFG!/sH?RuG 6lL APPROX.BORING DEPTH 15 a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: MOLE5 WILL N07- fib LEFT OPEAI <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 &tyCµ-. K/I� Title/Company F-jll� S{r5TF,44.5 Lt.1cIsLlL�.�FsL!7'j <br /> Print Name ITAYRN KR(EN5 Date 3f/(o <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: IJ <br /> Application Accepted By µ•V""5-a Date Issued 3 b'I Area R l <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: -tAA1 10Y- fiUN L <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 1 31-2110b SR# d !6$ <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 />