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spa I :� • • FILE COPY <br /> San Joaquin County <br /> �l Environmental Health Department SITE <br /> y.< 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> kj <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd M-. J UNIT IV <br /> 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 /> M644fw4 p Assessors D— <br /> WELL Location /q3� W- GPMf L(aQ Rd Cross Sireet t /�.CiTly T_ r4�Zlp Is39/ Parcel# $.09— o` <br /> PROPERTY 7:''' Cie �J ! RL Zip �q� <br /> OwnerrAize Csf Marilyn Address ,�• (,Itwfma�S R ✓rr Phone# <br /> C-57 Contractor �W�T (n6 Address I?D• BOX 1116 Citv*c/v p-6yn zip uw7Z09d�Phone#(9/6)777'Y�Do <br /> Consultant/Sub CntrAA1/Qce-kkk/� ASS6GAddress.3glOWHaM'4e,- LNSCity Liao Phone#4I)2j1`-T7yL <br /> GIS Coordinates:X �BA .Y ,Township S RangeE Section ((,p Ot <br /> WORK TO BE PERFORMED: <br /> )(NEW WEL /BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> 0 SO BORING# 0 OVER-BORE. DIAMETER <br /> fTRACTION <br /> # NG 0 PRESSURE GROUT <br /> r GROUT SPECIFICATIONS <br /> INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS !/ <br /> HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: a' <br /> 0 AIR HAMMER DRIVEN CASING THICKNESS_Se 4 NO TYPE OF CASING: O STEEL VVC 0 OTHER: <br /> 0 MUD ROTARY DEPTH OF GROUT SEALn &r TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br /> ZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: )(Yes O No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> O SOIL BORING O HAND AUGER GROUT SPECIFICATIONS n?,o-f G_/1.74 <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH ;LS 0 BOLTED TRAFFIC BOX or VTOVE PIPE <br /> CONDUCTOR CASING PROPOSED AIO (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 Ordinances, Rules and <br /> Regulations,and all applicable California State Laws. r <br /> Signed X-4 "�'�'i— - - TitlelCompany 1��// (.deb(0�9isf/�9El --Ku41 `' <br /> Print Name <br /> Fr�d W. Caius Date_ q%A a6_ ?O <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: �LfO <br /> Application Accepted By Date Issued Area 6 6 u' <br /> Grout Inspection By Date Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 21 1) 97 130MV I SR# ©© (F58 <br /> C-5 — WC_WAIVER_ C-57 Letter of Authorization to sign permit_Encr ment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />