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'c U'►v San Joaquin CountySCJ �� <br /> Environmental Health Department Z <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT ly <br /> Well Permit Application =;-► <br /> U " <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 /> Jo m Count Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> alJin1C` cam-• nom'2 � / Assessors <br /> W L Loca' 1 UZL- '(-e ` Cross Street FoodWi v7 �,-City Zip 9.�3fiG Parcel#,Z 102 <br /> PROPE TY <br /> Owner � Address-13W J111P�116SICitv5,WeA."Zip )0 Phone# (00 "Yf SZ <br /> C-57 Contra--ctollr Address 156 tke,Wt) tt c�City�Zip 0Lic# ®hone# X31 58430 <br /> Consultant/Sub Cntr Address��IS Sr• *.4 City Lic#Phone# <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> '-dKIEW WELL/BORING (CPTGEOPROBE, YDROPUNCH,HAND-AUGER,OTHER`) p DESTRUCTION (choose type below) <br /> OIL BORING# a OVER-BORE. DIAMETER <br /> [I WELL# a PRESSURE GROUT <br /> [I*Other GROUT SPECIFICATIONS <br /> COMMENTS 1 CPT bQ4 !MSArllli <br /> LA <br /> � � �adl�nQS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS G MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: o STEEL 0 PVC a OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Il AUGERS a HOSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER: a OTHER APPROX.BORING DEPTH Q 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 Ord' anc s, Rules and Regulations, and all applicable California State Laws. �f�may., <br /> Signed x Title/Company T�T'� `Eb /0 <br /> Print Name %(u'. Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: S Si le Ae q9 Fas t <br /> WORK PLAN DATED: l 06 11 Z !ll <br /> Application Accepted B V�,`g�}o r f g� L. m x zfkr b' Date Issued Area <br /> Grout Inspection B --_Date� Final Inspection By 0 7e <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: i` Yo <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 63 - s ' 7+00 sR# 0o 4. cI47 <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 />