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•San Joaquin County <br /> Environmental Health DepartmeR SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 953(Y2 2 LLS MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www."IRW"' AT HEAL h UNIT IV <br /> ``F0 Well Permit Application PERRRir/QE:RVIrrs <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,C apter 9-1111115..3 and the Standards of San Joaquin County Environmental Health Department. <br /> • 'CAA-A rrWON�/ �u"t G+r�r� �ZGAssessors <br /> WELL Location I� Cross Spee�t /Ci Zip Parcel# <br /> PROPER Y f lJ <br /> Owner- ;,.K -1�4eaA�ddress '1-p,� .N-- y�#i99 City S e—kIOI Zip turlD ZPhone# �/3 3-,�f7ap <br /> C-57 Contractor TEtS `/ Address 1135-0 H7p-n,'er rg ik/�/,City Parclk Zip?17YZLic#70&S(oBPhone#V/.-frSi�b-O�L/ <br /> Consultantiyr,D rK Address 3 2h F. w z/ city Atu r Phone# X04-728-3a 7!s- <br /> GIS Coordinates:X $7°$(r SY• ,Y /2/0/!s'S?l•✓,Township Lj/ Range 6� Section PS•� I <br /> WORK TO BE PERF <br /> EW WELL ORING CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> 0 SOIL <br /> O WELL# DOVER-BORE. DIAMETER <br /> 0.Other a PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING IOLLOW 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 BOTHER: <br /> `6APOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE RUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING O HAND AUGER GROUT SPECIFICATIONS Pcr SSC reti j �S m S <br /> 0 OTHER: H OTHER APPROX.BORING DEPTH fS— -a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 1 CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS:_ I'yQ C� �' �(r we a 4 1--� /Yj lil-i— <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 rdinances, Rulgs and Regulations, and I applicable California State Laws. <br /> Signed x II�� �//w?iC(/ . /, t- Title/Company �O <br /> Print Name Ll,✓'�I:k k - (.t�at�/ �� �6 J 7j Z —Date. 2 <iJ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDR�SS: -t- <br /> WORK PLAN DATED: I I I X cq, <br /> Application Accepted By IA1nn.,..r Date Issued 7�(2-7-/O f. 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 /> dqol 1 10 8-j-" C) (4_((4 ( ��u o6 SR# L�S� Po <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 />