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pRgUIty "-an Joaquin County <br /> 2 , oGz Enviru..mental Health Department SITE <br /> Q <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 /> gtr�oR��P <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 /451/ twtf11-Y Cross Street ✓ City 944o== Zip x-.13 Parcel# 3.2( -ZOO-3rg <br /> PROPERTY A <br /> Owner S!�/1t�, 14 SYI/KICJ� XAddre'ss/1G (CLI 4(RSCity 1FC9M)4.J Zip�I-Phone# <br /> C-57 Contractor L�01/lLc�/K�eQ(X C1�l1! / /�'/t�'ABtSdess�8,?7 5ho7w"Pu City_&L"��Zip Lic# Phone# �7-/00/� <br /> Consultant/Sub CntrtQvanc&1t4eo& !✓ wMdress o-47 �`8t.y � city SAX/- Lic# Phone# ��p7_1"67 <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/ BORING (CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# /D 0 OVER-BORE. DIAMETER <br /> WELL# 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE /•7J '0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NA- TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL old'A-+MC.XTREMIE TYPE TO BE USED: RAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE kPUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes gNo (/NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS rwit�ac ecel1� <br /> 0 OTHER:_0 OTHER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> / CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br /> COMMENTS: 04& <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 andRegulations, and all applicable California State Laws.. / /� �— <br /> Signed x Title/Company///L(t/�nlam U�G�q1/l►'�/Y�/ll/ <br /> Print Name W Date &/7-10,6 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date 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 I SERVICE REQUEST# INVOICE <br /> S R# <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 />