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- - , SpA•"•' San Joaquin County -���/�(�. <br /> i Environmental Health DepartmA���� �"l h1 SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.orFfi0 0 2 2007 UNIT IV <br /> Well Permit Application ENVIRONMENT HEAL;T <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUPED'MITISERVICES <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,a/nd tithe Standards of San Joaquin County Environmental Health Department. <br /> WELL Location �2510UX+1- 5UV4,1--1V f Cr ss Street ���C�`�C City �4Ki- Zip 9.5 Parcel#Assessor076-NO-SZ. <br /> Le✓t e_ <br /> PROPE'TYII •// `/ ( / / 11 <br /> Owner L,6 uh h e�/,1 /+ kce( USS dddress 13x5 � I/'� 55 City/ ,' c`' Zip q,' -2YO Phone# 3318- 7Z/ '3 <br /> C-57 Contractor 1 G (S Address_ ((3u�b /*o ry,,,- ��k��c�{y �i.��o Zipc/s ?yzLic#7b65_6 Phone# 0116_F15_3_cFv/v <br /> Consultant/Sub Cntr Pt/1P�`10 Zf-C- , Address -32If 2 e�7• /Y City'W& P4 Lic# Phone# 7 Z n-30 74 <br /> GIS Coordinates:X 3a 1 0400 FfC> ,Y 17- '3 zy0G U ,Township `Y Range Section L- <br /> WORK TO BE PEREOM <br /> PEW WELL BORING (CPT, EOPRO— B `E� iYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> $SOIL BO 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0`Other GROUT SPECIFICATIONS <br /> COMMENTS: I_� L.JI,, cL* _t,Im"-4y & 5 19vat.S .4yySotw..r�/rn <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 /> I/APOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE ,KPUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Pea, $7"C S�Q�, (��r o✓�5 <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH /J 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> C CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS;_/1/ � C� 1371!'Gti_ <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 Ordinances, R les d Regulation and all applicable California State <br /> Laws. <br /> Signed x ( �' Title/Company �L v <br /> Print Name C.v 1 woerf Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 21217-1 a .) e A4c, 12,.0 . <br /> WORK PLAN DATED: I i 15-1 C>fo <br /> Application Accepted By \ Date Issued Z-�Z/0 Area <br /> Grout Inspection BDate _2420[0 Final Inspection By c,_ Date Z O <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!SERVICE REQUEST# INVOICE <br /> 3.9to I $S79-00 I Iz t, uv z 2 o_T SR# `-i 9 60-q- <br /> C-57— WC--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment docT <br /> EHD 29-02-001 <br /> 6/22/04 <br />