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FILE COPY <br /> �o�°`•'•' .. o CENEDD San Joaquin County <br /> Environmental Health,Department SITE <br /> Y3t� 2 � <br /> `%t East Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> ) 3449 Fax: (209 468-3433 Web: www.s ov.or /ehd <br /> _ ONMEN q�� t > �g g UNIT IV <br /> RMIT/S�hVICES <br /> F 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 Joaqu County Environmental Health Department. <br /> WELL Location 1 933 5- D-o /3L � � yAssessors�pq a4 <br /> ^� ross Street*F�R14NrUN� City &0�110 U ip � fv Parcel#_�_� <br /> PROPE t� V <br /> Owner /12J MAgK= dWMV1JM0 Address3120 094 �4_City 7,W(1 Zip gZ&Phone# 2*4636-M-0 <br /> < <br /> C-57 Contractor krona Address52l2 !)"ECD t"D. City f'ACKiXu Zip ic# Phone# 7!a"521-5,21 <br /> Consultant/Sub Cntr_SA, lic Addresslfti b"W"ANCity Lic# Phone#51�J-y33-o83S <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> * WEW WELL/ BORING ( PT, EOPROBE, Y�c�PUNCH, HAND-AUGER,OTHE *) p DESTRUCTION (choose type below) <br /> SOIL BORING# N Q�'�",',_ _'p� l�/S�6V a OVER-BORE. DIAMETER <br /> WELL# e 0 PRESSURE GROUT <br /> 0*Other "b—'1i/ OW4 to c Z6Q0$()19 GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 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 MUD ROTARY DEPTH OF GROUT SEAL 251 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> p AIR SPARGE/OZONE APUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> XOTHER: O OTHER APPROX.BORING DEPTH A 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 ave repared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinanc s, ule nd Re ulations, and all applicable California State Laws. u" <br /> Signed x �/► Title/Company S�1,oe- '?63scr Ma► y t <br /> Print Name l•r t Cyd. Date III29 Ip b <br /> — y(DAE,�PARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS:_ �r / Q.dldy nv lath" <br /> WORK PLAN DATED: <br /> Application Accepted By Date IssuedArea OkjW <br /> I FAA <br /> ai,", <br /> Grout Inspection By Date Final Inspection By -mate <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 /> Z9o1 O8 z , sR# Q®�l <br /> C-57 WC *-/-WA IVERC-57 Letter of Authorization to sign permit_Encroachment doc /✓' <br /> EHD 29-02-001 <br /> 6/22/04 <br />