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�nao � iN r San Joaquin County <br /> Jill .:` Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209) 468-3449 Fax: (209) 468-3433 Web : www.sjgov.org/ehd 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 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 /> r7 j � , 1 ty arcel#Assessors <br /> WELL Location 1Q�7 ��(1c,4C N� RVYITC✓ Sf, Cross Street YZC �'�', Ci rJ rl zipZU,2. Parcel#� <br /> PROPE,�2TY �i a <br /> �Owner( .`/NO. _5 .k/0ji A ,)r{t+�ln—�5 ddress_?7 N % �Idnv dO :S1717F, rCCity S{vr Yl ip /0 Phone# ('do 937�`/t3349p <br /> C-57 Contractor C— SCa..O rpdressl � 7V� -, [ IQ$TrAQ, ONL CityNoYWuI Zip�W—/�ic� '� �1��(} Phone �,L ` " jam' <br /> Consultant / Sub Cntr FYAVQVR'PLY (7C26itV AddressM7. 7hf.GW&tCI' City xcraci LLic# e6.22 Phone# W°/ 4�97 ^/00(p <br /> wnti,&- <br /> / 2S Coordinates: X., Y , Township Range Section <br /> 10 WORK TO BE PERFORMED: <br /> XNEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") 0 DESTRUCTION (choose type below) <br /> a SOIL BORING # p OVER-BORE. DIAMETER <br /> OWELL # S we I I S U PRESSURE GROUT <br /> p `Other GROUT SPECIFICATIONS <br /> COMMENTS: 4mAoy ia-pyUna., WcU,4 QyA oBelle OPE /'Ptuor'IiCrf-7 (xn �W�( -� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 'MONITORING HOLLOW STEM DIA. OF BOREHOLE g MULTIPLE CASINGS g MULTI-LEVEL WELL CASING DIA /�4 r/ <br /> EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS S(? 114O TYPE OF CASING U STEEL )rPVC 0 OTHER: <br /> g VAPOR g MUD ROTARY DEPTH OF GROUT SEAL B i 1461 TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br /> Q AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT) GROUT SEAL PUMPED: Wes g No (NOTE: MAXIMUM FREE- ALL DEPTH IS 301) <br /> g SOIL BORING a HAND AUGER GROUT SPECIFICATIONSQ, ') 2� IA'l" S r' <br /> a OTHER: fl OTHER APPROX. BORING DEPTH 41) / )a OLTED TRAF C BOX or U STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NI:i.D - (if YES, list specifications in comment section) <br /> g COMMENTS: hw00-DI rn.L ws eRR2DIst "" DIRE 1nwe. 0 .301 sy rrp .n <br /> i —O <br /> b NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS, <br /> 1 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> CountyOrdinances, Rules and Regulations, and all applicable California State Laws. r <br /> Signed x ' /�v ` /I[ y Title/Company Y''I�� Gt��U�l S } 1 { VGM rL•2(� �ek�Ck U <br /> Print Name 01Y) 1 � 1 et � Vvt � C Date,A011 00S <br />� DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED : <br /> Application Accepted By I, ' Date Issued G �� Z0� Area <br /> Grout Inspection By _ Rate Final Inspection By Date <br /> Destruction Inspection Date <br /> COMMENTS I CONDITIONS: er -(• rzo a Ca U-Mi a' 011 <br /> ACCOUNTING ONLY: b FAG# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERM / SERVICE REQUEST # TINVOICE <br /> 3s t8� z 9 _ 3 0 236cXj / V Z OS SR# ! �{ t) 1 <br /> C-57 WC WAIVER_ C-57 Letter of Authorizon sign permit_ Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />