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San Joaquin County <br /> y % Environmental Health Department__ SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA'95202' ' MITIGATIONTE <br /> o P' (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> Well Permit Application /00 UNIT IV <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 /> W E[ttELL Location Ou/NER f/8C0 S, i/ARI AA/ Qp cross st eeIRDTH /1L, city lAT!!/100/' Zip`�5330 p reel#rs�`16-03a-03 <br /> PROPERTY DZFEAKE' L06/fYAGSAE•6NCY( SaoRrr4q FAP "�.a.° a0y�835'- Y/�9 l�+iNG['=i�+AiY <br /> Owner ?/l/V k CA�ZO LU/N(�QAddress_II Ir'T f#4a4A1 R city 6//1,Q0 , Zip 9S,�fO Phone# u <br /> C.57 Conlractor(y:QC=6G I''ent/� Address / r0 NC[�E go- Cit41ARr1A1EZ Zip cl s/ phonety -�JI3-.��1D0 <br /> �1O 9s�3Lic#/ <br /> Consultant/Sub Cn//tr URS O�CIP/� Address<O 7B(q] /,pgy(�,�r(iS CityS .C�ir11Ff'l4-ic# Phone# �l(o, (07"/-�OR7 <br /> GIS Coordinates:X(y 337/�10 fSD ,Y �/33y If,I(o ,Township Range 9 Section <br /> WORK TO BE PERFORMED, <br /> g NEW WELL/BORING (CPT,GEOPROBE,HYDROPVNCH,HAND-AUGER,OTHER*) G DESTRUCTION (choose type below) <br /> 0*SOIL BORING# 8 OVER-BORE. DIAMETER <br /> NELL# ME[ 5''Z/o A / ZONES) �ov /far/7o' ` <br /> (]'Other (1 PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: SFE .4n2fN.fD 5l;re0Y,67/-A1 MAP An/A AL&jL_ s�iCiiiCA��,yS y!i!3 r <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLErO�&W 0 MULTIPLE CASINGS II MULTI-LEVEL WELL CASING DIA:L, �v <br /> a EXTRACTION �����,p,,,,,,,/////AIR HAMMERIDRIVEN CASING THICKNESSSrH 170 C TYPE OF CASING: 0 STEEL KPVC a OTHER: <br /> 0 VAPOR MUD ROTARY DEPTH OF GROUT SEAL ARIES TREMIE TYPE TO BE USED: flAUGERS 0 AIR SPARGE/OZONE Il PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes O HOSE 2,QVC <br /> (]SOIL BORING X' U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> HAND AUGER GROUT SPECIFICATIONS OQjy//Nr1 <br /> OTHER:_0 OTHER APPROX.BORING D ' /70 ?ort D BOLTED TRAFFIC BOX or $',STOVE PIPE <br /> SO' CONDUCTOR CASING P OPOSED oVe (if YES,list specifications in comment section) <br /> COMMENTS: 00 {J-2c%/C a/EcL r�VST/J[[Ev /aY �yO[c<°W j'/♦:/0 ' /Ve • / O' c0'N&i6 s' gyA9UD CTrJ tv <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinance*,Rules <br /> //and <br /> �Regulations, and all applicable California State Laws. <br /> Signed x /�rLln<C Title/Company_ <br /> f-1-r99rpn69Q' <br /> Print Name �/DHA/,'1j V N' dYKL / Date pC i e�l�i 2ooS <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted B�yyv� ,,,,,yQ ( ,/ Date Issued llb D l <br /> Grout Inspection By kYFf,..-p,P ----- nate Z! 7 / a 1 Area <br /> —�.-t F Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> 0. <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 19-01 �`j- 84 - Sb/sS� IJIC !t�'j oS SR4�yY7/ <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doe <br /> EHD 29-02-001 — <br /> 6/22/04 <br />