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I <br /> WELL ERMIT APPLICATION F M SITE <br /> DEC 10 2004 MITIGATION <br /> SAN JOAQUIN COUNTY F <br /> ENVIRONMENT HEALTH ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> PERMIT/SERVICES 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <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 9-9115.3 and the Standards of San Joaquin County^iEnvironmental Health Department. <br /> i <br /> 212 3no�v,s����1 fl r. ur Ln. S-b(11'.�or) Z; q,5'2106 Parcel#Assessor's <br />' WELL Location Cross Street�� __City p Parcel# /77zi8 0/17 <br /> PROPERTY Owner H E Sf netr i A Address 2 I Z Z ndt S+T:1 a 10,-City S hKk Zip 462,06 Phone#—Jka_—0708 <br /> C-57 Contractor Fi do Cr1v. Address 3CACi 511 Cr,S PINCf� City Sr?��5 Zip 45UZ Lic#G036foSPhone#772—35 <br /> -70 <br /> Consultant!Sub Contractor Gt-o,nck Zero A--,A 1.4 ddress 71Lk /Al ;n 61}-, "City EScglon Lic#R_Cy504Phone# 831—id b <br /> GIS Coordinates:X Y Township Range Section <br /> I <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION(choose type below) <br /> J SOIL BORING# 7 0 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS: y 19or,n s SO 2-940', 1 e k0 r ! <br /> i <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS T0E OF CASING: 0 STEEL 0 PVC 0 OTHER; <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL' 0iV,\ 'Oept4 TREMIE TYPE TO BE USED: 0 AUGERS I HOSE <br /> 0 AIR SPARGE I PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 Noy(NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> E SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: 0 OTHER APPROX. BORING DEPTH3&E,_(.0rn ye/%r- 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here); <br /> *COMMENTS:_Li go-1 r,P,-4 0 6-0 r 2 40 1 0 to <br /> E <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED 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 an� gulations, d all applicable California.State Laws. i <br /> Signed x_ r—�v/� / y Title/Company v GT�4'tl" � �L� j�i✓ff�- S is <br /> Print Name Date ! 2 g 0 q- <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 212 T- n.at t1 s+r i a l :"j)-r > v e <br /> WORK PLAN DATED: Se,1216 Im �, .200 + <br /> Application Accepted By U 1 c h e A. M e;j�g rfn a4, Date Issued 1.2 0� _ _ Area +� <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# r <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 350 t X9.00 8 9. 00 sg# d04 072 S <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 1/25/02 <br />