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COPY <br /> rad qirry San Joaquin County <br /> Environmental Health Departuree t��r, `-'%' � ' SITE <br /> we '� 304 East Weber Avenue,3rd Floor, Stockton, CA 95wjg MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd' ���� <br /> \� P' UNIT IV <br /> F� Well Permit Application po <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 /> ,' s ® d� Assessors? gq 1 2 <br /> WELL Locat <br /> i <br /> ��o <br /> yyn zpp /��[/�P-e—^A Ag; Al Cross Street S�' City 114rix Zip Parcel# LJ 1 .! <br /> OwnnerPROPForvW�f'�7 d Z4,Codress Vo I4s B� q P <br /> _ Z � S�-c 210 City OyLVi fit Zf Q9�s�6�6 1phone Yt -\F 0 p <br /> C-57 Contractormc �7C�IofQLrlyll¢P"Aldress95h LOVA R� w;B Cii�tyZB�rin�o-r/a LZiip! bTD Lic#?$33Zb Phone# 53D/�J`GZ-Z�21 <br /> Consultant/Sub Crur'E(O:G &16 Eng. Address IN h 4! 5�C ty nLic# Phone# 1-Dj-z7 Z-OZ9Z <br /> GIS Coordinates:LJ . • �"'ITaw ship Range Section <br /> WORK TO BE PERFORMED: <br /> � <br /> EW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> Q SOIL BORING# a���/ U /r� 0OVER-BORE. DIAMETER <br /> %KNELL# W,_ t- O //[SGT/ 0 CA/p/e a PRESSURE GROUT <br /> a•Otherrr GROUT SPECIFICATIONS <br /> COMMENTS: X07: 61(0,QI a'zw Q?.Cly+ " dr//h2-1 /Z/-Zpk lG An 4(, UA777e" 04PV4 o <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING )-IOLLOW STEM DIA.OF BOREHOLE rr EIIJ,M^^ULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:_( <br /> a EXTRACTION 'a AIR HAMMERIDRIVEN CASING THICKNESS�c� TYPE OF CASING: 0 STEEL >JPVC u OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL + ^Io' TREMIE TYPE TO BE USED: O AUGERS u HOSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes/a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS N GSI l ff$Tjy{ ��d <br /> a OTHER:_G OTHER APPROX.BORING DEPTH LO-Z54 0 BOLTED TRAFFIC BOX or` STOVE PIPE <br /> c f �COCDUCiOR CASING�RO�P�D _� YES,list specifications in comment section) <br /> \ COMMENTS: <br /> It, <br /> J V <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS, <br /> I hereby certithat I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Or ces, Rule d Regulations,and all applicable California State Laws. <br /> Signed x ; - / Title/Company t o LO o r <br /> Print Name /1au+ j-��t17ZFiC Date -31Z a <br /> DEPARTMENT USE ONLY zp�� <br /> oe i <br /> SITE MAP IN UNIT IV FILE, ADDRESS: /ZZI <br /> WORK PLAN DATED: � <br /> Application Accepted By Date Issued 7"�l6'0 T 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 REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR# DSOz53 <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 />