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ECEWED <br /> San Joaquin County <br /> z 's r '1 4 200-17Environmental Health Department SITE <br /> Q0 E. Main Street, Stockton, CA 95202-3029 MITIGATION <br /> ' <br /> R, AITV•�n�{� �lyy. ` i� 3449 Fax: (209)468-3433 Web:www.sjgov.org/ehd f if ry DW <br /> R`'F•R� Well Permit Application <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 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> ZlO S. ./h�1N S�% MoFF�►T /`��►dT�G 9§336 AssessorsZZ -OZO " 27 <br /> WELL Location Cross Street City A Zip Parcel# <br /> PROPERTY <br /> Owner/`1'1�G Gr+Si7 `t�. Address Z/4 S_ 1'7,-,," City�� A Zip956Phone# �it0 -7G�0 5 &(� <br /> C-57 Contractor �,�1LLi AJC:-r Address M r i •lllGTc Z -R-V- City L.P/ _Zip�5Z40Lic#720��Phone# ,IGG"-777 <br /> Consultant/Sub Cntr�'0~�'6G� ��' AddressCityG?,a Lic# Phone# 9/�"%72 - f4"� <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT,GE R E,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> ;SOIL BORING# 431 S V'7" 6v1$16-, 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE2'/O 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS — TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL O-Z 0 FTTREMIE TYPE TO BE USED: 0 AUGERS )CHOSE <br /> 0 AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Cl)�t'ti l <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 2"> 0 B LTED TRAFFIC BOX or 0 STOVE PIPE <br /> _ CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: �/ G ] �uSN S,Ar-r�'Gj•'G <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordin , Rules and,Regu`"Ta'flo�ts, and all applicable California State Laws. <br /> Signed x —Title/Company <br /> Print Name Sdv /Q- /�'�'` ����t� Date -3 ' 73 2 >7 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: Z10 S ryk'wM S <br /> WORK PLAN DATED: <br /> Application Accepted By �J��•�.M r/ � Date Issued t � 0 1-- Area 3 L <br /> Grout Inspection By V i GtD r 0, C�rJ Y f 7t6� Date (,-1$ . Final Inspection By vi 1 dT r Date_ <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: i <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SRI ®b5 0 <br /> C-57WC WAIVER__ C-57 Letter of Authorization to sign permit Encroachment doc <br /> EHD 29-02-001 web <br /> 6/22/04 <br />