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COPY�o ut �a *an Joagni:County 11 r <br /> r °ice Environmental Health Department SITE <br /> U) 1 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> q`rFORH�P Well Permit Application Y005 <br /> MAY 18 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED $A PM.2tt-i <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This apple A&rWff4nCcpmpliance with San <br /> Joaquin County Development Title,Chapter <br /> .,9-1111�5..3vand the Standards of San Joaquin County Environmental Hea �� ���-rtt MEPP UINT y <br /> WELL Location - )"I"CV Va(S"C'P0-" Cross Street 11 city kfl�Zip 0 Parce'1r! 022' <br /> PROPERTY W.W• QbID((ll<I bl7d� <br /> Owner �}pYYG 'bVCk� ,S Address 10'2(4 �}. , Clty5 + Zip_7_5 e# ? —y78' h�\ <br /> C-57 Contractor CQ r9r,.0 `�rt��ty Address -N(QU, O .L Cityffa)M Zip9'67o74Lic#71-L 1 Phone#41('9b3 � l\ID I <br /> Consultant/Sub Cntr C^ hlSl(L Addressloal D(a PIOWI 4 City4i.ua,tlerHa Lic# Phone#41(a 3(O o'-2 -7100 <br /> 210 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ANEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') D DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> WELL# P,S- 3R 0 PRESSURE GROUT <br /> 'Other GROUT SPECIFICATIONS <br /> COMMENTS: TnS{B.�( A'rI fUR_ caT211 �S-2s 3 d CD(1r1F r } to �SVSIG� I iY12 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS r <br /> 0 MONITORING HOLLOW STEM DIA.OF BOREHOLE2_-2$0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESSOu S•tJ"ad STYPE OF CASING: STEEL PVC OTHER: <br /> p VAPOR MUD ROTARY DEPTH OF GROUT SEAL SO'I r TREMIE TYPE TO BE USED: 0 AUGERS HOSE <br /> -(AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ',Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS NG'AT <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> r , CONDUCTOR CASING PROPOSED NO (if YES,list specifications in comment section) <br /> COMMENTS: �x'eer\ R5 -90 <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 In �R/Iu�IE\s a /d} IR,e.,gnuI t11'ons, and all applicable California State Laws. <br /> Signal Y-�/�17wrvgwr"' • / Title/Company <br /> Print Name T(fA U AJWE-A Date <br /> `DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: d b Sid Cj s <br /> WORK PLAN DATED: pf-L/ <br /> Application Accepted By Dale Issued 6 -:31 - 0 -s Area d 60/ <br /> Grout Inspection By Date 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 I SERVICE REQUEST# INVOICE <br /> SR# P)O ZSR/2 <br /> C-57_ WC=WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc l, <br /> EHD 29-02-001 <br /> 6/22/04 <br />