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a u c an Joaquin County <br /> Envir nmental Health Department 40 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 /> w0vt 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 /> Assessors <br /> WELL Location$O'Z W. WPe1n¢-r /A-l'C Cross Street (-JAmly% City St'o ck*-an Zip 95203 Parcel# Lq:5- -01 <br /> PROPERTYrias, tjo./naL l7'l n� * <br /> Owner E.S. Wllki aynr, _ ,4ddress P ?Sift -7155 City �oCkiov\ Zip CP526-7Phone# 2f��X1 -473- y02Z <br /> C-57 Contractor Qs--r- Address 22y N. Ga&C -5- rP CityWt�c(Ia frolzip�Liat$o2'-31hone#_ -Iob&-2417,9 <br /> Consultant/Sub Cntr'E6t.f'4h,.7PGh, Address(D65 Lj = Ci idk — Phone#cf!(a-UQ-1fl43 <br /> GIS Coordinates:Xy <br /> 'Y ,Township I N Range to F Section 1 0 <br /> 22 <br /> WORK TO BE PERFORMED: <br /> )(NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# 3 hD(� AjQ!S c�njt %jaf&f cCiJU �F 0-r% 0 OVER-BORE. DIAMETER <br /> 0 WELL# f 0 PRESSURE GROUT <br /> 0.Other GROUT SPECIFICATIONS <br /> COMMENTS:_ _SV-2.4 t 6\)-2-14a , SV-2S <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _ <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS — TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: — <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes VNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> `('SOIL BORING 9 HAND AUGER GROUT SPECIFICATIONS ('i0 MP#l4 <br /> 0 OTHER: Il OTHER APPROX.BORING DEPTH 5}O 10 647 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED I (if YES,list specifications in comment section) <br /> COMMENTS: VI W i <br /> NOTE: OFFSITE BORINGS RQUIRE 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, Rules and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company_ eelybpsI - lear4 TPGI. <br /> Print Name L,c ( K�A1 Qn is ItA &9,Lk Date '71%7-1057 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: �0� 2 <br /> Application Accepted By 01"-1 Date Issued ` ✓ Zitf Area <br /> Grout Inspection By 47 Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# R C'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> --A2158 M sR# LI'303 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorizati o sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />