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fut <br /> © q !! .,c L'Ian Joaquin County <br /> Enviro,.mentaf Hearth Department SITE <br /> '� ={ 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: wwrv.sjgov.org/ehd UNIT IV <br /> Well Permit Application Nil. <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDIM `��''I `� t <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application`i5,9 � lance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental 1'ib-aithgq�apa�trp j� y; �t� ' <br /> / �ssessors <br /> WELL Location 145-1 ffal� ��,,¢� <br /> - �! Cross Street City dip �3 Parcel# L7 2�-Zor�'s?3 <br /> PROPERTY e <br /> Owner SPW� 5;14�'/l�ll/A)(k(Address <br /> /IW Get�l14 '(RSCity S�(9FWJ -Zip��Phone# <br /> C-57 Contractor L�01/lL4niEQ(,L'_(?4/G/ 4w"A'Ah ess �17 5`P--'Pu� D ,City..&Ltf�—Zip Lic# Phone# 7-1004 <br /> Consultant/Sub Cntr/7�f✓RW, d&0&� �C12i►7W4dress A7 5�ew 4 v4 city Sit,4AK, Lic# Phone# 147-(y66 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> KNEW WELL/ BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> DSOIL BORING# t!_. 0 OVER-BORE. DIAMETER <br /> WELL# ^�^ 0 PRESSURE GROUT <br /> *Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE /-75"n MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS Nk TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL A6•L+MAWLTREMIE TYPE TO BE USED: §fAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE kPUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes gNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> V'ISOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS larf( ,u <br /> 0 OTHER:_9 OTHER APPROX.BORING DEPTH IO 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: ��<< Bir/^�s - n✓Lev� w <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 Ordinancep, Rules and egulations, and all applicable California State Laws.. <br /> Signed x Title/Company VP /f/Gl✓fin//� U2/G,�d�►'IMNY-K[/`�� /l�L <br /> Print Name A `✓ DateCO/7-A).6 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FIL ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued �ZC/ �� Area- <br /> Grout <br /> reaGrout Inspection By Date c�? ob Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# F <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> el 0OV-7 t Kr <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 />