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`"'fan Joaquin County i >rte'; �f r� <br /> Environmental Health Department ` U �1SITE <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95202 :p .;OOMITIGATION <br /> (209)468-3449 Fax:(209)468-3433 Web: www.sjgov.org/ehdy� k � ` <br /> UNIT IV <br /> Well Permit Application <br /> ENVi RO 1�;v,E11.r. HFE41TH <br /> PER 11.11/03E9VICES <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 /> c) �) / I r j p/)_ Assessors <br /> WELL Location ?J{ 5W WI LI niL�vl 5T• Cross Street ctt , kk City /LLpC"'+i Zip 59ZZ16- Parcel# 7/`6 5703�)4 1 <br /> OP <br /> Owner I�TL�1til�`� 5l^GlIG11 O�IWff Address'JA W 5L'1�_6 1,7 City 5 &6'11 Zip 15203 Phone# 2122— <br /> C-57 Contractor -l+SCii o ti11i�� AddressA37— oyr4C. Cirtp City+ rlZp i574Zuc#7)7SIU Phone# <br /> Consultant/Sub CntrJt2' )Fviv i r;,,^,yytib A 1W Address aU�``�1 '�'"�( �•1City ��'n` f/LIQ � '�Z Phone# 531 ,�'Z 7p 7 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ` NEW WELL/BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> a SOIL BORING.#_ a OVER-BORE. DIAMETER <br /> VWELL#`fA') I`ll' -`;1 5-- 11 P Jam_ a PRESSURE GROUT <br /> (['Other v1tbL'_11;,Wi9i'-i ,°ittr>j-1$.'Yi'!GL' iii GROUT SPECIFICATIONS <br /> COMMENTS: <br /> I) N <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFIC NS C110 <br /> `d MONITORING HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS 5444,40 TYPE OF CASING: a STEEL �,OVC a OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 1r'Gt/ia Q TREMIE TYPE TO BE USED: a AUGERS <br /> a HOSE <br /> AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: •�WYes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER: a OTHER APPROX.BORING DEPTH a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> I �Jj (r- 1�CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: 5etaA&261 Glt�t� ill tVi.�[ i�iZG7• ��a, { ';ed 'y r a f/� <br /> f �U( Duval '� k,I 4i r /'i V! w-tlb 14{1!/1!/l�1Iiky;C �v> <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 Ordinan�ces,Rules and Regulations,and all applicable California/State Laws. T� _ <br /> Signed X Title/Company Cir.�� 5�l'r5 '"t�; L'�fl2�T2 /� ,jk <br /> Print Name t �vT+r,.'4'lir--VI Date —% � <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 02 5- <br /> WORK PLAN DATED: /c/ <br /> Application Accepted By Date Issued 7 lJ Area <br /> Grout Inspection By _70C Date 7. i Final Inspection By V� AAS a,_ Date t <br /> Destruction Inspection By 0 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 /> �qo � �� M V,,- - � d�y TS R# sy <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 />