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V1 .••ro San Joaquin County <br /> G� Environmental Health Department RE C, ff V Lrr--,' U ITE <br /> " 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehgPR 9 6 2065 UNIT IV <br /> Fr, P Well Permit Application ENV(PIONMENT HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ERMIT/SE:RVICES <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 /> / �p Assessors <br /> WELL Location ���� Yi NI�� c✓� Cross Street city e G6P Zip Parcel# <br /> PROPER1014,V ( �/1�hone#�`�'1L5� <br /> Owner lrl��U * Address (,� � ��*���'� City Zip� �, �/J <br /> C-57 Contractor hh n l-// Address 3055110��(A&&_City G ' ip& Z�c# /I7S/ahone# %10*&36i/�`r1`� <br /> Consultant/Sub CntrC8 r Address �� �Sf?ag) haZl City Lic# GPhone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> X-NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> FELL# �f/J 0� -7- �/f/3 0 PRESSURE GROUT <br /> Other T GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLEMULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: Z H <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS !�(2 TYPE OF CASING: a STEEL a PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 1�-' TREMIE TYPE TO BE USED: [$'AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ,ryes 0 No (NOTE- MA vine+IS- -- —-,LL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_G OTHER APPROX.BORING DEPTH BI� Or' 'n Q t' x 0 STOVE PIPE <br /> CONDUCTOR CASING P OPOSED G ns in comment section) <br /> COMMENTS: (�! <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT 5I�� 0 S T PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR IK <br /> 1 hereby certify that I have prepared this application and that the work will be c San Joaquin <br /> County Ordi nce Rule§ and Regulations and all applicable California State <br /> Signed x Title/Company--," <br /> Print Name Wim► 7 Date !Xz �,�e`� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 4040 EASt MLti rt, St1''ee <br /> WORK PLAN DATED: M Q V n2,�0, Z 0 0 4- A �7 p <br /> Application Accepted-By Via -r 1 Q L. I V 1 C r Date Issued /t r, I a ! -2- O 57 Area � 4 S / <br /> Grout Inspection By 7/A/,6 CNnM/19, Date i S— Final Inspection By Date <br /> Destruction Inspection By D to <br /> COMMENTS/CONDITIONS:=1D r0 J rt W r Yn /1 S _ -I MT-2-,&W-3 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3501 q,ao $ a0 SR# 0042078 <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 />