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' San Joaquin County <br /> ;& 'GA 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 /> mat/F,�R��P <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 /> M R1c=-nzRF 0V Assessors <br /> WELLM <br /> Location OK&LUMNC- RSUER Cross Street kwy I City CLEmegr5 Zip g522�Parcel# 023 -010•0I <br /> PROPERTY <br /> Owner ESm UD Address ZOO() CRMA(Ir-MG R9 City p"(! zip 45640 Phone#204•_463.5121 <br /> wesr <br /> C-57 Contractor M420CL G)M(xTANrS Address 391 Wcsr cAPrwPay City SAcRA&WZip95G91 Lic#y66270 Phone#9//,•3721.1690 <br /> ��••� "�� Su=t6 Zoo <br /> Consultant/Sub Cntr YQO I ST, -ViuC• Address iOM BUADw1lr City 0 ri-W.9 Lic# Phone#Sl0.26¢)•Oq 61 <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ,XNEW WELL/BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> YKIL BORING# 0 OVER-BORE. DIAMETER <br /> LL# 0 PRESSURE GROUT O <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: QcLcQ ttJ4Tek ScR &16.5 -gyp /Qa L <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOL�E6''�� 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS. TYPE OF CASING: ArSTEEL 0 PVC a OTHER: <br /> 0 VAPOR _ D ROTARY DEPTH OF GROUT SEALT°Su"IIcE TREMIE TYPE TO BE USED: 0 AUGERS XHOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: $Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Cilk <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS P60.•TL#A/9 CEMe An C <br /> 0 OTHER: BOTHER Qoc l - CARL, APPROX.BORING DEPTH 100' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> pQt <br /> LCONDUCTOR CASING PROPOSED �+ (if YES,list specifications in comment section) <br /> COMMENTS: ` ,` ) ! Z <br /> r7A <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. c <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Z° <br /> County Ordinances, Rules an Regulations, and all applicable California State Laws. WC-5-1, <br /> •• '' <br /> Signed x A,ta.( ! Title/Company 1T5SOCT#TE ! FtlC'RO WC 5-1, Ste. <br /> Print Name I.stne1�(d _>M11'sort� Date Co 0(P <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued I bl D(, Area Iq7 <br /> Grout Inspection By Date Zi Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: L,JD r itLl <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> Ig _21 . I 2L a I[K) I�ge__ =460 to SR#00 q7 M� <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 />