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um' Count J�T COPY <br /> San Joa <br /> l`c4 9 ' <br /> &nw*ronmental Health Department SITE <br /> t Weber Avenue, 3rd Floor,Stockton,CA 95202 MITIGATION <br /> * r �209J 468-3449 Fax: (209)468-3433 Web:www.sjgov.org/ehd <br /> N t 006 W UNIT IV <br /> ell Permit Application <br /> ENVIRONMENT 1 EFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �� !"r"`', <br /> Application is hea ht�' J Sah'�/(oal " - <br /> quin 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 /> Assessors <br /> WELL Location At`Z hCross Street C'dy y����f C1Jl Zi �'�3 Parcel# <br /> PROPERTY <br /> Owner Cx-�A '�0. rr� -Address IC[-,1 V,�, nV rho{-City Zip�Phone# <br /> C-57 Contractor_ r Ol r.t ca]L? 3X11 T Y 7Address P-U '�© Ln City L' \/� Zi ?I Lic# 710019 Phone# 707 7`l_-14-Y Cj <br /> nsu nt/Sub Cntr._CwlyG WL �2ckv��C Address 11p% ��� � Citp-N Lic# — Phone# (ZG4)`-)Z2-- L- Il� <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL!BORING (C GEOPR BE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> (I SOIL BORING# p OVER-BORE, DIAMETER <br /> ,IfNA+ELL it 0 PRESSURE GROUT <br /> 11`Other GROUT SPECIFICATIONS <br /> COMMENTS: G <br /> TYPE OF WELL ihlSTALLATION TYPE CONSTRICTION SPECIFICATIONS <br /> MONITORING 11 HOLLOW STEM DIA.OF BOREHOLE,_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _ <br /> EXTRACTION Ia AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING. 11 STEEL Q PVC a OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: U AUGERS it HOSE <br /> 11 AIR SPARGE/OZONE Il PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes 11 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS <br /> (I OTHER: 11 OTHER APPROX.BORING DEPTH _ _ a BOLTED TRAFFIC BOX or C1 STOVE PIPE <br /> ^` ` CONDUCTOR CASING PROPOSED Of YES,fist specifications in comment section) <br /> COMMENTS: ` - 0'-t �� L�l?r �' v� r' O �� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 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 x6 c .UCWicP Title/Company Vi <br /> ZA L4n-,&� <br /> Print Name J GO'tT— y GN(E Date ,T—X6-0 6 <br /> DEPARTMENT USE ONLY N6)t <br /> nd <br /> SITE MAP IN UNIT 1V FILE,ADDRESS: <br /> WORK PLAN DATED: - OS <br /> Application Accepted By Date Issued Area <br /> (� <br /> Grout Inspection By 12 Date_ le& Final Inspection ate Ob <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 /> so z 3("& OIF/gB b fs sR# �D D� <br /> C-57 ;'CZ-WA VER._ C-57 Letter of Authorization to sign pertnitA9kricroachment doc /_ <br /> EHD 29-02-001 ((! <br /> 6/22104 <br />