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D' Asan Joaquin County <br /> Env>< nmental Health Department SITE <br /> m 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 /> �o- <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 /> Assessors <br /> WELL Location. WP-S+ LUo!btr Cross Street l,l/ICAIVI City S�"OC.I"�kirri Zip Z0� Parcel# <br /> RTY <br /> OOwneE ._C. WilllOLn"DPfOOAAd)raQ-D flm'x -2M5 cityrS'4aG����1^__>nn' ����Zip95261Phone#a-O�j-CJ-73 4 Z <br /> - 0 Z <br /> C-57 Contractor 915M Address 8a0 N• Ica �IrfY,L�,l,' City Zip%7- Lic#9-0153V-&&&-Z42.Ci <br /> Consultant I Sub Cntr E0.M1lti�T2 r.4x Address Lr�Q55 tih�V�YJI , `A~Ci�.ic# Phone#91 <br /> GIS Coordinates:X ,Y ,Township I NJ Range (0E Section /D <br /> WORK TO BE PERFORMED: <br /> XNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> XSOIL BORING# It) i0t)(JAp D OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0.Other GROUT SPECIFICATIONS <br /> COMMENTS: SV-0rSy-�ga. iSv-2OrSV-Zf Sv-ZI SV-21arSy-22 SV-74A.,3V-2.331L-230. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLES 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 /> 0 AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes *I(No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 'SOIL BORING aHAND AUGER GROUT SPECIFICATIONS C-Oynft+_n-��rtuvt <br /> Ci+ <br /> 0 OTHER: p OTHER APPROX.BORING DEPTH o 10 y(•O,F p BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: ren (Ab} <br /> -ro bk cQ LA-� Cern-p le s,-. <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, Rules and Regulations, and all applicable California State Laws. <br /> Signed x AM (- Title/Company 6PP(V2�+- I F"n,CYr Teck-' <br /> Print Name—( 4-0n L'.t-" 64.1 Date 21124 0 S <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: �I. </ <br /> Application Accepted By t' Date Issued �/ H (/ Zoo v Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: lel oO%r #Vt r. o11 D In/Z <br /> ACCOUNTING ONLY: AID# Q. ev�t 0.9a -'tom "ViouS Poe Z <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> Z�01 91100 pV :T [S/0,1 SR# qI3() 33 <br /> C-57_ WC_-WAIVER_ C-57 Letter of Autho iz ' n o sign permit_ Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />