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'OPQU N.,c0 San Joaquin County �� I� <br /> ? Environmental Health Department SITE <br /> { 304 East Weber Avenue, 3rd Floor,Stockton,CA 09252 D 1 2,006 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sj%y,,q>rg/ dl,l.f HEATH UNIT IV <br /> �R Well Permit Application PER I`vli�1-�i_)VICES <br /> OPY 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 /> ,, I I�_ r�'� )� Assessors i <br /> WELL Location /07/ A)dt( r/' 4A, h V- -Cross Street 1-0LI;Se City ��'f�� �� Zip ��3�� Parcel# zl-7-U <br /> PROP TM GtaY7 7; lata/,e TR l4LSL C. Lou/-se mllrlt�e� 9S33G <br /> Owne�1_t l tel/r r /1 Address 17 City�Zip Phone / �`-'- <br /> C-57 Contractor &oe r- It n?Address LlJ� l f�l�t/N //�/G'�(c� /Cjity GI�'�1 clgipgW's ' Lic#les!�SPhon/e#(q2 S) 3�3 Ii <br /> Or� <br /> Consultant/Sub Cntr(%M bK A__ Address.27 0 pe(K1 r6 O% City'S �Licff r Phone#1707 q:35- i 6 <br /> GIS Coordinates:X �7 • �I� -J5 2- _,Y - i L 1 i-Li 7.-7 7 W,Township 15 Range f l Section -32- <br /> WORK <br /> 2WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER') `DESTRUCTION (choose type below) <br /> a SOIL BORING# a OVER-BORE. DIAMETER <br /> 0 WELL# OPRESSURE GROUT <br /> 'Other GROUT SPECIFICATIONS <br /> COMMENTS: (f-e53 L nt G-F1 pYl of 3 6),)5i4 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS, <br /> 'MAONITORING D HOLLOW STEM DIA.OF BOREHOLE []MULTIPLE CASINGS []MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL O PVC []OTHER: <br /> Q VAPOR o MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: [I AUGERS HOSE <br /> Q AIR SPARGE/OZONE o PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> OTHER:_0 OTHER APPROX.BORING DEPTH I]BOLTED TRAFFIC BOX or IJ 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 /> County Ordinancd Reg ons,and all applicable California State Laws. <br /> Signed x ' Title/Companf//� <br /> Print Name V �� Date �h D <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 1 0 7 1 N o rf i C1/ a i n Si. Ma YJ e c,Q <br /> WORK PLAN DATED: !=e b r«a ,^ ti ) S_ Z 0 0 0 <br /> Application Accepted By 1 . Date Issued 2 -2 1 -0 Area 145 <br /> q <br /> Grout Inspection By Date - -0 C Final Inspection By, Date 7-2 9 06 <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 /> 3502 G0. 00 60. 00 SR# 0C) � 8$ <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 />