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- San Joaquin County <br /> Envienmental Health Department SITE <br /> 600 E. Main Street, Stockton,CA 95202-3029 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> L 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 Joaquin County Environmental Health Department. <br /> yl, Assessors <br /> WELLLocation 2566 ����&IQC. Cross Street rl, S��City`__�Zip Parcel#-/ti7.-/�-d! <br /> PROPS ,` <br /> Owner -+)'1 �'�v�%?si..1 Address 7t06 AIA�iy /�.11lIC City ip _Phone#2Zd `73"7- 7 ' <br /> C-57 Contractor Ural/1LNL2%i�x;l J it V AddressAb,:b=I3% 97,0 City &N Zip:%�/Licl1 ' Phone#�!ti �/•�'�^✓? <br /> 60w�J3>z��h/t•TH %$S'Ft3}NKWtSi <br /> Consultant/Sub Cntr l�N'�u�IAtl 4AV Address/�a'�/'e E„r!S" T. � '1Cdyic# Phone# jj?.: D�iS� <br /> GIS Coordina er/ ,37°Jen/�s �i1J.Y�/Z/o eDI//i.�ru.�Township�� J)FRange /1.1 E Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/ BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0p OVER-BORE. DIAMETER vA� <br /> IlWtF.LL.#.�3 -.rn atn. -F �� APrac�ooRciaROUT <br /> F✓1411�f u <br /> 'TY p Other GROUT SPECIFICATIONS ml <br /> COMMENTS:/J.rjr GAc,xr AjyA /tC�I' -"'E.-i✓nAIL` '. /7rIFL�-/,4Ri�C lj— /JE-j7=,1 u /A'r PJJf� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: a STEEL 0 PVC a OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS p HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> OTHER: Ua OTHER APPROX. BORING DEPTH u BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br /> COMMENTS: 7 Z-/AL//.a //) L/L L)/FZta/'IAC%L�4 /IJf S' Ffz:� 0Eq1 /}-I <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 Ordinanc , Rules and ulations, and all applicable California State Laws. <br /> Signed x �iu Title/Company�SSCI�-! F L-7th/./(c.7A.UdO)j2_� <br /> Print Name Date .�T /�7 <br /> DEPARTMENT USE ONLY 7 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �`� VW C"y j uhrAj- — <br /> WORK PLAN DATED:: S— -- <br /> I z7 -L-0 <br /> Application Accepted By f/L"ac' Date Issued L. Area -5 `L <br /> Grout Inspection By Date Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# F <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 2Ito ;tea-ate D.c�J as3 B�,La�v"F- SR# D-5rILo7- <br /> C-57 ✓WCC WAIVER_ C-57 Letter of Authorization to sign permit ncroachment doc_ <br /> EHD 29-02-001 web <br /> 6/22/04 <br />