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�Iv:a San ,loagtlitt (vonnty FILE COPY <br /> $' oz Environmental Health Department SITE <br /> Y 304 East Weber Avenue,3rd Floor,Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax:(209)468-3433 Web; -Anvvw.sjgov,orglchd 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 pernit to construct andior install tie work described. This app6:ation is made in Mmpiianse with San <br /> Joaquin County Development Title,Chapter 47115.3 and Iho Standards of San Joaquin County Environmental Health Dopar ment. <br /> WELL Location 501 ross Sires, W•150 �JC-� Assessors <br /> i,,,, f�, ,m ty �Zip.L�" d-,3.- Par,.ot# 1!a 0Dr�t. <br /> PROPERTY Vt'blPl�ur.o(, 1]W wurt7-:'-- (i�'- Vvt r"WL4i-GY- 4J.Avu.U1 1'Z-�' <br /> Ownern Address 3_4—ro .�`7` cna16- <br /> -aaa��oW <br /> C-57 Contractor-- NA Address — Cly Zip Uc# Phane# <br /> Consultant Sub CntrC, w� Ktit Addresses ' p' iDDOCIty�`}Q Uc# Pharfa#_N D% ,ayy (e <br /> GIs Coordiraios:X ,Y •Township Range Section <br /> WORK TO BE PERFORMED: <br /> JkNEW WELL I BORING (CPT, EOPROBE, PUN'�C'�HYy"" BE OTHER DESTRUCTION (choose type below) <br /> $SOIL BORING# Y4P tTu'E DOVER-BORE. DIAMETER <br /> U YVELL#_�,_, 5{M't.xl. Dh. LC , PREBSI*2E GROUT <br /> D'Other GROUT SPECIFICATIONS_ <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRilCTION SPECIFICATIONS <br /> D MONITORING D HOLLOW STEM DIA.OF BOREHOLE D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DA; <br /> D EXTRACTION DAIR HAMMEWDRIV€N CASING THICKNESS TYPE OF CASING: D STEEL D PVC D OTHER: <br /> O VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMfE TYPE TO BE USED: D AUGERS D HOSE <br /> D AIR SPARGE/OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED: BY% IkNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> JILSOIL BORING DtIAND AUGER GROUT SPECIFICATIONS neQ-l— C'1.re,.vv'r <br /> D OTHER: ❑OTHER APPROX 8ORIRG DEPTH _t �} D BOLTED TRAFFIC BOX or DSTOVE PIPE <br /> CONDUCTOR CASING PROPOSED '--' (if YES,rst spoclfications 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 egulations,and all applicable California State Laws. <br /> Signed x TaefCompany v,(AU _VYPAia <br /> Z ;iT <br /> Print Name -15 <br /> DEPARTMENT USE ONLY q <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: 22005 <br /> Application Accepted By _ _Date Issued a? '^s. !??g1 Area <br /> Py <br /> Grout Inspuction BY. _Date _Final Inspection By <br /> Destruction Inwisclon.8 Date <br /> COMMENTS f CONDITIONS: <br /> ACCOUNTING ONLY: ND# FAC'" <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT f SERVICE REQUEST# INVOICE <br /> 2Y0 !0 SR# fln <br /> C-57" WC WAIVER_ C-57 Letter of Authorization sign perm Encroachment doc_ <br /> B 02.0,1 4� A41 ;� -� �JCa Ll LI.C! SYS-�'`-� <br /> �" _`� /3_ do . L <br />