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San Joaquin County <br /> Z Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 2�0� MITIGATION <br /> .,, <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd AUG 3$jW W57 <br /> Q �P <br /> r�oRa Well Permit Application SANT <br /> EMVc"uir couNTY <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED HEA l 7H IRONMEr,T DEPA RTT��7qq`E <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 compti3hth San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 0-- _1 1--� 1 h y+ ., Assessors _ -7l6_�� <br /> WELL Location 1560D Soog I1cykn et>Aa Cross Street 3 SlfMf city <br /> � Le111 foP Zip 1' O Parcel# //O e� <br /> PROPER,L�YY 11''YY ltlllVd Zi T is Phone# ZW"21 Zto43 <br /> Owner IrK �11DU� Address K'600Saithlbr� Road City p �Q p <br /> C-57 Contractor . Address 7t �ov+Q(C.t�'CIC- City�WlD'"A Zip'1nY7Lic#�Phone#2LA-6i8"IIA19 <br /> W <br /> R lom f yy dk <br /> Consultant/Sub Cntr 5ROR, Address-300 ki4oft atC� CIb9 b _Lig# 6517% Phone# 14-16l- W O <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> EW <br /> WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) []DESTRUCTION (choose type below) <br /> KSOIL BORING# p OVER-BORE. DIAMETER <br /> NELL# YAVJ._10 _ p PRESSURE GROUT <br /> p*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS q <br /> MONITORING OLLOW STEM DIA.OF BOREHOLE-a a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: Z <br /> n EXTRACTION IR HAMMER/DRIVEN CASING THICKNESS 561140 TYPE OF CASING: p STEEL (PVC a OTHER: <br /> p VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 3/ TREMIE TYPE TO- USE p`AUGERS a HOSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes %<No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS neotl- aM-1 t+ <br /> Q OTHER: fl OTHER APPROX.BORING DEPTH IS OLTED TRAFFIC BOX or a 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 Ordinances Rule and Regulations,and all applicable California State Laws. l C1 n <br /> Signed x � Title/Company fiL, 15} J�`� 1` <br /> Print Name ' �ol WvYj�•t� Date <br /> DEPARTMENT USE ONLY <br /> p <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 5 (o O a td�-�rn o`f-7Ana�o <br /> WORK PLAN DATED:_ $ t) S <br /> Application WT 3pted By Date Issued DS Area <br /> Grout'Inspection By Date 1j0)' a Final Inspection By t24 Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: I <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3 � 3') f 3 -3 4 3 CI/13 SR# q.31 d <br /> W <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 />