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U1 <br /> r.N <br /> o San Joaquin County rr <br /> i Envi�ahmental Health Departmefit�i�i�' SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 ErMITIGATION <br /> " (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.old2 6 2004 UNIT IV, <br /> Well Permit Application ENVIRONMENT HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED/TISERVICES <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 ofSanJoaquin County Environmental Health Department. <br /> 2 q-Sy� S MgAj jAjj & Cross Street I 1 t� Sf c ZiAssessors <br /> WELL Location City G� p Parcel# <br /> PROPERTY //�� 1 ) / <br /> Owner_yJ-eSkt-A Re(t( �%-.,,»,Address 28"2!(,E b�,Ll4Ad FD 1/K CityFfL,-(114410Zip 33386 Phone# <br /> C-57 Contractor W ��� An Address N&Y q1 4P Cityr�-45), Zip fy6q l Lic#72a9oY Phone#(7/6)77 7^y/� <br /> Consultant/Sub Cntr AAz--,c qA �u y Address M`/7 MShi. Way CitySShu'r Lic# Phone# <br /> GIS Coordinates:X Y Township S rG Range 2 s Section ' <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') DESTRUCTION (choose type below) <br /> 0 SOIL BORING# )gOVER-BORE. DIAMETER R'� <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS t{ 11,4- CeAP-1 <br /> COMMENTS: -bt 4l DJ+ 4,C1 grrb 0 Tile- /btwells _ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 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 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH 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 <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: <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 /> Count=inances, Ru s and Regulations, and all applicable California State Laws.Signed x ` Title/Company (ZS 1 rke—n aL� rwy 1 X�1�iYi�t* �Yl� <br /> Print Name V Date <br /> DEPARTMENT USE ONLY <br /> � <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 2 �I S b D c Arm <br /> WORK PLAN DATED: N A <br /> Application Accepted By Date Issued Y130 -0 Area <br /> Grout Inspection By # Q Date Final Ins ection By Date <br /> Destruction Inspection By Date g u <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 /> SR# 31 L(3 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br /> ERD 29-02-001 <br /> 6/22/04 <br />