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L F If dMoaquin County fl&nan <br /> r o`� Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 JUL 1 5 2005MITIGATION <br /> (209)468-3449 Fax:(209)468-3433 Web: www.sjgov.oL*PA0NMENT HEALTHUNIT IV <br /> L a '` Well Permit Application PERMIT/SERVICES <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. 3 2 2 00 0 <br /> ) Assessors <br /> WELL Location 425 Z41r �. I�cz� Cross Streel� ¢tid•City TroKIZip 530 ParcepF <br /> PROPERTY <br /> OwnerrjMdR rTra,41sp-?(63n Address35?? W. A1u14 ,Iity Zip L—,ypPhone#q09'36't- `do <br /> C-57 Contractor Wr.tiA5 DCr I t tic4 Address G100 k64 �Z Cityly-COs 1zip�iyh�7l.io# Phone#3o 8233184 <br /> Consultant/Sub Cntr 65A lyl c . ,,11�� Address35"13 Pki toi?d(P"_MtlyO[2faj Lic# 2B Phpone# �e1�-36/4-a(95 <br /> GIS Coordinates:X-74/A-.Y NA- ,Township ftwt SPetrrtanga W action <br /> WORK TO BE PERFORMED: - <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') n DESTRUCTION (choose type below) <br /> n SOIL BORING# n OVER-BORE. DIAMETER <br /> WELL# 191 2OL' .I g PRESSURE GROUT <br /> p-Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING I HOLLOW STEM DIA.OF BOREHOLEe Q_ M LTIPLE CASINGS g MULTI-LEVEL WELL CASING DIA: <br /> n EXTRACTION g AIR HAMMER/DRIVEN CASING THICKNESS_ TYPE OF CASING: n STEEL I PVC n OTHER: <br /> n VAPOR g MUD ROTARY DEPTH OF GROUT SEAL 3> TREMIE TYPE TO BE USED: J AUGERS n HOSE <br /> n AIR SPARGE/OZONE n PUSH POINT(GP or CPT)GROUT SEAL PUMPED: n Yes I No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> n SOIL BORING n HAND AUGER GROUT SPECIFICATIONS r% B1n MAge_ CPM✓ S w.r21 Yl LC)c <br /> n OTHER:_0 OTHER APPROX.BORING DEPTH oQfi 'bas I BOLTED TRAFFIC BOX or n STOVE PIPE <br /> CONDUCTOR CASING PROPOSED Al 0 (if YES,list specifications in comment section) <br /> COMMENTS: <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 dinances, u e n Regulatipns, and all applicable California State Laws. <br /> Signed J�' Title/Company r— 7 �!rh /RCA 4�. <br /> Print Name 22, 1' Date n -1 11— 0!75 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 4-2S 1 G1 YGI� 12 t7QLA r <br /> WORK PLAN DATED: May 6, -20 05' <br /> Application Accepted By Date Issued —1 - Area /459 <br /> Grout Inspection By Y`at/lr i G_ L,y}J&/Dale - 05' Final Inspection By ale <br /> 8 a -05 <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3501 3L9.o 300 SR# 00¢3z7S- <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 />