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11�an Joaquin-euffffty �° ��� FSE .COPY <br /> oq,4.....-.c <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 952oWN.3 0 2005 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgoaraJhdENT HEALTH UNIT IV <br /> Well Permit Application ryPVE1RMIIT/g RVICK <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 /> SOD, Q f�ft_ Assessors <br /> WELL Location Cross Street 6dX54E5 Cay V4' zip 5ao7Parce1# 097-410-73 <br /> PROPER ,( :J�l <br /> Owner J,»�S' G,.Pe,/'IAddress 37q L.4 cath Cf� CitySIxp�Clfo-� Zip 5207 Phone# ?05-476=$e2 Oo <br /> C-57Contractor Wood Wov."d- Address Po 13-OX 3 3 City R.,e%)k ziP5 57 Lic#P0077 Phone# 707 374-43 0-1> <br /> Consultant/ Cntr � FieAddress City.):7.r Ae-Lic# Phone# 510-G 5.2- 4500 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> vkWEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER•) O DESTRUCTION (choose type below) <br /> a SOIL BORING# a OVER-BORE. DIAMETER <br /> JLWELL# AS-Z)- , a PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING HOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: a r <br /> a EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS Sc tt 40 TYPE OF CASING: a STEEL ,$PVC a OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL LI 7 ' TREMIE TYPE TO BE USED: 0 AUGERS U HOSE <br /> , AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes jfNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS IVe ii R' Ce"" - <br /> u OTHER: a OTHER APPROX.BORING DEPTH 55 r BOLTED TRAFFIC BOX or a 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 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations,and all applicable California State Laws. <br /> Signed x ` Title/CompanY_ fx^ol�Cat <br /> Print Name .1 off 4 Kot' -<'k..55. . Date <br /> ,D�EP./ARTMENT USE ONLY <br /> o <br /> SITE MAP IN UNIT IV FILE, ADDRESS: F � /Ve-C .{•'�� �C c•✓2-�✓QC�3/S"r=s <br /> WORK PLAN DATED: t((''p\��'-)lrj-^OS y^ <br /> Application Accepted By )r#c�{'�"'�— Date Issued-T. b S Area Q� y <br /> Grout Inspection By Date Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 2Ro1 Mw a4 .-- gq (�I is -3o SR# ebVZ 3 <br /> C-57✓ WC WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc 1( <br /> EHD 29-02-001 <br /> 6/22/04 <br />