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k'ADtee - Tf r.3A r� J i.C.`f` S'ot' p ,SLS l� �Ca2 S�� -, '[�' I. <br /> San Joaquin County �Rc' <br /> �za 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 /> FORWell 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 9-11 a he Standards of San Joaquin County Environmental Health Department. <br /> 206 &� � �^+ , Assessors <br /> WELL Location Ss-rc- A A,- Cross Street C41r-TT o.>"-/- City Zip y 5 3 Parcel# <br /> t�1c:3 h i nci t-0 n S7, <br /> PROPER --�� / J c <br /> Owner a�iFc." (n4pr,zYppcAddress `aC(o(;,,,r-assn ST City Jr�crzoAJ Zip)S�p3Phone# <br /> .QCs.c-L_pgtz, <br /> C-57Contractor Address FoLlY S"T , City 1d4`fU1 zip`)yS_' Lic# jV0`'Phone#S00—k9_7--(,6SR <br /> Consultant/Sub Cntr 1�01ntt/l7Ynr�v,i(ti(� Address3iS10?�Sratcnl�nL City tnl• tn, Lic# Phone#g/6_-.3�/-Cy3y <br /> 2 vac <br /> GIS Coordinates:X 'Y Township •1 Range %Z- Section <br /> WORK TO BE PERFORMED: 3 <br /> ANEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> SOIL BORING# j 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> O'Other GROUT SPECIFICATIONS e /!� <br /> COMMENTS: /K0 /1 W <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 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL /.S-jnTREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONEXPUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes// 0 No ((NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS /Vra C em�r� �riE'S F4rc <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> pn / CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: //�.� O 5 Z G y�U <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 a Is app ' ation.,and that the work will be done in accordance with San Joaquin <br /> Cou rdina e e Re lations,an applicable California State ' <br /> Laws. / /f <br /> Signed v / Title/CompanyP,yy SY.COQ 54l I Zane-,i �Pu2e_6 1•u-C, �tC, <br /> Print Name 01 o /l Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: C w pp0 Cr� CL <br /> Application Accepted By Date Issued 7 o:f- ENVI'rR.OMAENT � T_"q y <br /> Grout Inspection By Date Final Inspection By PERM E3 — <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS:.�1'I d-<C Ov►. L✓G�� .t�ly <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> /441-- SR# <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 />