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REodED <br /> FILE COPY <br /> San Joaquin County <br /> Environmental Health Departme &V - 9 2005 SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 959! <br /> MITIGATION <br /> ' (209)468-3449 Fax: (209)468-3433 Web: www.Sjg <br /> P, gNV(R®PI111ENT HEALTH UNIT IV <br /> `'FOR Well Permit Application PERMIT/SERVICES <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 StandardsofS Joaqu'n Cou ty Environmental Health Department. <br /> �/L 1aG y .,1FD�KA _ p Assessors <br /> 0 / ? <br /> WELL Location 'SI'h1ly oss Street Cit r7 Zi Parcel/#� V� ( -7 <br /> PROPERTY - -�34.��( /' ..,� Cityj Zi��Phone# Z.'-1 �d <br /> Owner Address-344�eeC.wIG.-('.�t <br /> C-57 Contractor t1T. [ Address�4�o 460, ' Q4i City d; Zip il! Lic#-3MPhone#4�10), 2!.X'?''X'1� b <br /> Consultant/Sub Cntr LQ.Lrr/.'nt a:& Address /& 9a,k/1 5ke f city&V. _Lic# Phone# Crt0oa <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> (NEW WELL/BORING ( PT,GEOPRO BE HYDROPUNCH, AND-AUGER,OTHER') D DESTRUCTION (choose type below) <br /> T� <br /> RIN _ <br /> LL# 26�-OVER=BORE�IArv1ETE�_-._ <br /> �y/I �7i1+�9�1F�j _ <br /> D`Other jv9-4/ntr2/0. et �-il ;1♦r•l4 D PRESSURE GROUT <br /> I r OUT SPECIFICATIONS <br /> COMMENTS:671,./__`ge�- my;a b He be till 1, -� <br /> � '�T.ri <br /> � *r'1 I7aut <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING D HOLLOW STEM DIA.OF BOREHOLF. D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA:_ <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL D PVC D OTHER: <br /> D VAPOR DJ-MUD ROTARY DEPTH OF GROUT SEAS 1D r j TREMIE TYPE TO BE USED: D AUGERS 41t8SE <br /> D AIR SPARGE/OZONE TUSH POINT(GP or CPT)GROUT SEAL PUMPED: D Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING DH_AND AUGER GROUT SPECIFICATIONS <br /> D OTHER:_a OTHER APPROX.BORING DEPTH 7'6"+I'- D BOLTED TRAFFIC BOX or D STOVE PIPE� <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: S'i ca a'k /tT 1ji`fan( A4. �L eJ, L <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 Ordinances, Rue an a ulation nd all applicable California State Laws. <br /> Signed x �A�t� { Title/Company .&rcLC <br /> Print Name /'M�fcl✓ 10✓'lfi�0Date 1(���6-S� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: g�.tr 9 l e/Q�2) <br /> WORK PLAN DATED: R"2f=j� wq-O$ <br /> Application Accepted By Date Issue Area <br /> Grout Inspection By Date Final Inspection Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> ;-fiH] <br /> E INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> B 4, 3f y sR# <br /> WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />