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AgUIN- San Joaquin County OVER <br /> Environmental Health Depart" SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgoVW/eAd 9 2005 UNIT IV <br /> Well Permit Application EPi RONM.,ENT HEAL]11 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATERSSLjV�T/SEIIUIC'ES <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 11®L� L �lh�O Cross Street City Zip Parcel# 45� -'4`p+ <br /> PROPER <br /> Owner gNnty Rin r, Addressmi's L. (�;1 �ve�• City. Zip'173U.Pho�n�r�i 914- <br /> Owner 3 <br /> w hn 1 S56 rte. yJf1G�w p9"+( S1LGIPhone#( �' <br /> C-57 Contractor f� V(Address IVL� n Cit Zi Lic# <br /> 41 <br /> Consultant/Sub Cntr 1 Y+zJC",�rtr L7t�NG+ AddressC VivtCt'A 1[�. City wq ) Lic# Phone# 5 � <br /> GIS Coordinates:Xyan"N Y 1ZI"oa.1`3 Q ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ,NEW WELL/BORING SCPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> ,,SOIL BORING# S _ -,01 5&-o?.— % a OVER-BORE. DIAMETER <br /> 0 WELL# yo0 0 PRESSURE GROUT <br /> 0 <br /> *Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING .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 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: M XIMUM FREE-FALL DEPTH IS 30') <br /> ;.SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS E.rYL L <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> iCONDUCTOR CASING PROPOSED (if(if YES,list specifications in comment section) <br /> � t ch <br /> &v,"` )A( ha &y,"dn 'Y. _]ja �� 115L�v`�m ll`-.'.:� tIS <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 Ordi ances, RuLes and-Regulations, and all applicable California State Laws.TT <br /> C /+ <br /> Signed Title/Compangl7,, �rKiSt / Lam- 7�.✓11t, CSrv---,� <br /> Print Name +;M Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRE S: 1-1p�3 <br /> WORK PLAN DATED: 5 LOS <br /> Application Accepted By Date Issued 5 1 I Area <br /> Grout Inspection By Date 3 Final Inspection By Date <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 /> ;w so C) �!!�A 10 SR# y'o1� d <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 />