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San Joaquin County <br /> Environmental Health Depar <br /> SITE <br /> 304 East Weber Avenue, 3rd Floor,Stockton, MITIGATION <br /> (209)468-3449 Fax:'(209)468-3433 Web: www.sjgov A*Td4 2010 UNIT IV <br /> Well Permit ApplicatiOnENVIRONM11ENTHEALTH <br /> NON-REFUNDABLE PERMR EXPIRES 1 YEAR FROM DIM" SER ' <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This a�i�lYdandn 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 /> S ool } 5, l4v6 \ Rd,/ (Mie W��11 �I J{ assessors <br /> WELL Location ­, - CroSsi ItreetS J'VYtX City Wr'Ys✓1 Zfp�53iJ Parcel# 40gp <br /> PROPERTY � / <br /> Owner Ci Address 10 11W (6h�y{ Di, ciry,"NT11 zip45i� Phoneu 2rc�9-9/1[-�y3 <br /> CS7 Contractor R T 1 rll syr .Addre's(s, L),d e �.NY( 5�. - City 6k'.4(4'0. Zip9r17b Lic#ydX)34 Phoned yid-6&t=1424 <br /> .. Consultant/Sub CntrS� SFAVi 'h-d'ari:ss3306,11t/ortP�+ ,DI,d ry Catry l�u $Gd Z Phone#_,�3�-(/Z,-�bO <br /> GIS Coordinates:X 'y Township Range Section rn G76-;b&o <br /> WORK TO BE PERFORMED: '- <br /> g NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# ` 15RESSURE GROUT <br /> a*Other r ( GROUT SPECIFICATIONS aA (1lltk� <br /> COMMENTS: Mw-I�AI(3r MIU-17JC , <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL g PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0.HAND AUGER. GROUT SPECIFICATIONS <br /> 8 OTHER: n OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (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 Ordinanc les and Regulations,and all applicable California State Laws. <br /> Signed 1l / Tille/Company y(Or1r S�' S / <br /> Print NameSte-I'X ITirn!AQ - Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: I Sb 0 O Q <br /> WORK PLAN DATED: ; JA- <br /> 'Application Accepted By �A /w� _ Date Issued Z 12I Area <br /> Grout Inspection By Date - Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS.- <br /> ACCOUNTING <br /> ONDITIONS:ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEEINFO AMOUNTREMITTEO CHECK# REC'D-BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3'5`02— �S�or� 2-�-4-rj1 12, 1a /o SR# 33S <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permits Encroachment doc_ <br /> EHD 29-02-001 <br /> 622/04' <br />