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man Joaquin County 'VON( '. <br /> Environmental Health Department` s , 0 , <br /> TE <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 95202^YfG�!f ��' MITfGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/ehd%,yt'.;-'1, _ UNIT IV <br /> �o' P <br /> ~L-FbRN� Well Permit ApplicationE <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 99--1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location_2�1v9 LpOrvy g np0.d Cross Street i-IW �� Assessors <br /> y City �J+Ock4-pr-, Zip ftSL5z Parcel# 17Q^ (l Z4 <br /> PROPERTY <br /> Owner MQraaa'21 K+arG"' Address 20 Mob�)a. CitY_C� Zil)�3 Phone# 707-41-(-,5-(;,0 1-5 <br /> C-57 Contractor\15 Vj 'Drl I11;jg) Address q-j� city._ * L7ZOgDgphone#_ <br /> ('_5 Oct)ic#� �a�d��s[ nt/Sub Cntr �<; �l T hnt �, Address t 101 -1 -,�yQe_} Cit) M�c1eLigr - phone#L2D0.�522-'�11� <br /> GIS Coordinates:X ,Y ,Townshi <br /> P Range Section <br /> WORK TO BE PERFORMED: <br /> p,NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) Q DESTRUCTION (choose type below) <br /> Q SOIL BORING# Q OVER-BORE. DIAMETER <br /> [,WELL - <br /> [I <br /> ELL#_ SSU- ! = pl E�){ �p CVJ EW 101 � EW 103i QPRESSUREGROUT <br /> Q'Other f <br /> A5- 1 GROUT SPECIFICATIONS <br /> COMMENTS: P Q(}PIC ��p✓IL P0.►- �.(� a Z ODtQ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> EXTRACTION C(P) Q AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: STEEL <br /> Q VAPOR Q Q PVC 0 OTHER: <br /> Q MUD ROTARY DEPTH OF GROUT SEAL <br /> TREMIE TYPE TO BE USED: 0 AUGERS Q HOSE <br /> $AIR SPARGE/OZONEC;b PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER <br /> GROUT SPECIFICATIONS <br /> BOTHER:R:CZ Q OT <br /> t n CZ) � �„SHER APPROX.BORING DEPTH Q BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING <br /> tC� PROPOSED <br /> COMMENTS: p - 11 _ Uh2Q Z(if YES, plstseacifictis mieoQpj Uf0't' m ) <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 Or ' ncRul s d Regulations, and all applicable California State Laws. <br /> Signed x <br /> Title/Company <br /> Print Name_ � C.`c^ �D���� . <br /> Date_ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 2 9(0 Q L o o m i s '_R o q 4 <br /> WORK PLAN DATED: JU n D 0 <br /> Application Accepted By V c 1 o r' L, M G (f- Y rJ Date Issued June-Y1 G 1 3 ZOO 'y <br /> Grout Inspection By Area S g <br /> Date Final Inspection By <br /> Destruction Inspection By Date <br /> Date , <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED ECHE/CK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> iso/a las;oo374. 00 9.3'27 SR# pOSD9� 2 <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 />