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,-an Joaquin County <br /> Qza Environmental Health Depart n `� 2" SITE <br /> �' 304 East Weber Avenue, 3rd Floor, Stockton, CA 95201 ����-=' <br /> ` (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.pr#/eV,, MITIGATION <br /> boos UNIT IV <br /> 40�/PORN Well Permit A lication <br /> Pp ENVIR01vMEN f HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE%ftpI ff SERVICE,- <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 /> Assessors <br /> WELL Location 222 yV�; }(� �)_ Cross Street V'f, 'T��t. City S1c�c,�F,- Zip q5 22CX:, Parcel# <br /> PROPERTYM . � �1 City G Address 222tOL 4,f112,A StoL <br /> Zip IS Phone# (AL-41A 62—'tr,21 <br /> C-57 Contractor I-VOi,4c Address `tSb Noy+e 12r. nn City a� E Zipg4S53 Lic#LS `/hl Phone#(rQ2S3 <br /> )31 `5B��C� <br /> Consultant/Sub Cntr Ar,'E Address a3-i 51�4.N a4. City .S4clr6t,� Lic#6$GZZ'7 Phone# (Z69)4Q-I bat's <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> W WELL/ BORING (CP ,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> $SOIL BORING# rPT-L----(LI) OVER-BORE. DIAMETER <br /> 0 WELL# rir <br /> copy <br /> 0 PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MU ROTARY DEPTH OF GROUT SEAL i l7C�' TREMIE TYPE TO BE USED: sl-ATGERS 0 HOSE <br /> AIR SPARGE/OZONE PSH POINT(GP or�;r i Z�GROUT SEAL PUMPED: a Yes gra (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING 0 HAND AUGER GROUT SPECIFICATIONS I vv aZ J. IT �ncFIF . <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH_ 0 BOLTED TRAFFIC BOX or 0 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 O76/— <br /> nces, Rules and Regulations, and all applicable California State Laws. <br /> Signed xx _ Title/Company Star �0n� <br /> Prin�me --1� ( C4'."PAI C' ` Date �'Z`�—O Cn <br /> G DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 2224 M ani t ev -Road , S+-D e 6n . r A <br /> WORK PLAN DATED: Fe b rLt zl r 4 17 2-0124- <br /> Application <br /> 00(zApplication Accepted By L (',0r4,,7,0!!j Date Issued Au LA S-"c Z00_6 Area )4s9 <br /> Grout Inspection By "\J i zdryi4 L.meta, Date 8 -Z-f-a 6 Final Inspection By ate 21 - 04 <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 /> 3So3 a 9'0o 368. 00 SR# 004 7729 <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 />