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qan Joaquin County <br /> [ I✓I,� DD <br /> Q• .� Environmental Health Depa� �� JOSITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, ce, 9,5202 MITIGATION <br /> s.` ` . <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov dr /a d-OC, UNIT IV <br /> Well Permit Applicatiohr ,`✓� <br /> cri r,.y,l ``_ r� LTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISS0�' -f�V�rL <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 /> rG „oCity Assessors <br /> Zip �WELL Location ,go"Se toe6g�, kOL"- -S Cross Street N, "3 <br /> Parcel# /312-3001 <br /> PROPERTY <br /> Owner Address 2201 GJ- 67R� City SGC4,ta:- Zip f5lz Phone#_ 209 9 44 - 02!/6 <br /> C-57 Contractor �C"r .d r r�Gv��Address �D y � p JS- hone# <br /> �T g hoZ� �o� Cit Zi ��! Lic# Phone# <br /> a I <br /> Consultant/Sub Cntr F!2 S C4>-A Address 14" f A/' 6A& City�Lic# ' Phone �13�—!GBzj <br /> 3 <br /> GIS Coordinates:X g �✓ , 7,l � � � 9 k ,Township (P � <br /> � �4 3 Y 0✓3 Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> A-WELL# 7 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> w <br /> COMMENTS: � x9 <br /> V� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING tHOLLOW STEM DIA.OF BOREHOLES 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 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: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS.30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Z <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 5,d 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> i�- <br /> CONgUCTOR;,ASIINJG PROPOSED (if YES,list specifications in comment section) <br /> �/ t� <br /> COMMENTS: 61,11 L"/ /��I <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 �l <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company S COY <br /> Print Name_'v ,0'VA Al L P4 E TA Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> �j;/ �i ! <br /> Application Accepted By [� Date Issued ()/ {., Area o/ <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: T o <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <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 />