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IEC�� V EI3San Joaquin County <br /> 9Environmental Health Department SITE <br /> t FER 1 �04 ial Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> NVIRoP&"t�tAffM Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> PERMIT/SERVICESWell Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES t 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 /> Assessors <br /> WELL Location 1810 f.N4 ttltOh Ave. Cross sweet (3 5tteet City $tOC KtO 11 Zip 95205 Parcel# ISS-ISC "02 <br /> PROPERTY <br /> Owner Scn jQQ%4j4 C04ht4 Address 1}21 E,ScottS AVO, City $teehtOh Zip9 20 Phone# (709') 66t-i 15 <br /> C-57 Contractor <br /> (,J000b0AM Pl2JLLA6el�{es City Zip Lic$ C- Plfo��lF L7 <br /> -7Oseylt R4 "tale pp 0. Box 963 <br /> Consultant/Sub Cntr Rath q'2 FhY rThG Address Ittthcho MYr Qtb CilyN5663 Lictt ((F 5$56 Phone# (916)354-3250 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: c DESTRUCTION (Choose type below) <br /> NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTH A')SOIL BORING# 0 OVER-BORE DIAMETER <br /> I WELL# SVE-11Al6 C1 26, MW-} 0 PRESSURE GROUT <br /> p•Other, GROUT SPECIFICATIONS <br /> COMMENTS: -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS - SEE W ELL Gc N 5TA VCT(OM 0 IA 49 A t15- AttACKEO # <br /> a MONITORING P HOLLOW STEM DIA,OF BOREHOLE_* a MULTIPLE CASINGS []MULTI-LEVEL WELL CASING DIA:---_ - <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SCN 40 TYPE OF CASING: 0 STEEL I PVC 0 OTHER <br /> E VAPOR a MUD ROTARY DEPTH OF GROUT SEAL * TREMIE TYPE TO BE USED: J AUGERS a HOSE <br /> p AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: []Yes j No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS NEAT CEMENT <br /> OTHER: 6IESTEO OTHER APPROX.BORING DEPTH &BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> MVLjI-VSE CONDUCTOR CASING PROPOSED NO (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, RulesandRegulations, and all applicable California State Laws. <br /> Signed Title/Company-10 N-5V ITIp1T/ RAMA GE ENVa ZN C, ___ <br /> Print Name 10 S E P H R R M A 4 E Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: ff �/ p <br /> te 65 Final <br /> Application Accepted By -Y t�w'v`�l Dale Issued a Area <br /> s <br /> Grout Inspection By DaInspection By {V- _ —. " (I Date d S <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3S-01 S` - 8 7y6 1-11/' o sR# p�/56x-j <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 />