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San Joaquin County <br /> 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 /> rFoR 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 Tale,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> ^�L �C C M ► �` 1 1, p l -� Assessors <br /> WELL Location 'U 11 A DNk'rossStreet WAozco {`n City 1reLc Zip X76 Parcel# a46- Igo-01 <br /> PROPERTY Clkcvto.'. Cocfar..40^, 6001 �o�l�Imr Gouyw► Rb/ $kA Ram*'" P 44Sd'S OsalS'-dya- I$Oy <br /> Owner uPRf, Address 94S1*144SM:i ,5{c W City ?'akAj1g__Zip"7 Phone# <br /> C-57 Contractor'R[.us�prl „t/qAddress 1`m 250 � J`''IO*S City�gt kMo�Zip Lic# 7Phone#S/0-o`137'-V7S <br /> Consultant/Sub CntrVGC�ma�yiX Co1s11�,<r�bddress �IOI 11la.�sler '54 City N+k Lic# Phone#SIO-66 3-41�[l <br /> GIS Coordinates:X 31. 7193 ,Y_ - la1• ya3 t Township Q 5VAlot Range_S Ec,S-� Section 33 <br /> WORK TO BE PERFORMED: <br /> EW WE,1.L/BORING (CPT,GEOPRO E,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> OIL BORING# la cl1tecA. !/SK Soij bct j^9S 0 OVER-BORE. DIAMETER <br /> 0 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_^-3 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS Uft TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL YA TREMIE TYPE TO BE USED: 0 AUGERS '0 HOSE <br /> 0 AIR SPARGE/OZONE A-15LISH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a'S`OIL BORING 0 HAND AUGER GROUT SPECIFICATIONSyPe Z'- Alipok 'po%�la v& <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH IS- or (s0 P4 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> ` CONDUCTOR CASING PROPOSED AJA (if YES,list specifications in comment section) <br /> COMMENTS: Six 50i� DChNS� �o IS �?S A h� S�X Sn� �bt r�S s �P Ann. 6-s <br /> TT 6-s <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, Rules and Regulations,and all applicable California State`Laws. <br /> Signed x Title/Company Imo-toiec6eo1cc s+ GeaN%cc�t'ac <br /> Print Name !�t�rO r% —T—U Tnc.r- Date 7�a 9�s <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# FAC# <br /> PE CODES FEE INFO AMOUNT REMfrTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 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 />