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101 Vol LDDL 117:4 f LD74bt d4J,3 Y It I H I-LIJUN VA6L U4 <br /> RECE `ED WELLIERMIT APPLICATION AM SITE <br /> JUN 2 3 2004 SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERMIT/SERVICES (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a penult 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 /> UPAP R .L+- S- w+y .<+r. tvts} Assessors <br /> WELL Location O� 1)r31 S. 3fort'Fa- St. Cross Street 1(944tenA..G4. City t-4 ziP Parcel# A( //f <br /> PROPERTYOwner Gtlt;aw Isar:Pt A&; r.aaC Address IIPOO Fa,ma... Sty City. 0,%44&iY" ZIP '( Phone# <br /> C�57 Contractor 1>r L°M ri��r tir. Address /�� /?a.-AO /tat , City/ti)a.,flti.04 Zip /KJUc FSS6 rfBJ Phone# �gZ5 3/3-$-�'aB <br /> Consultant I Sub Cntr fRZ Address AJO S.1--e i y. Sic,A City C ,,eo C uc# Phone# <br /> GIS Coordinates:X ,Y.Township <br /> 3/ Range A G Section <br /> WORK TO BE PERFORMED: <br /> )(NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER•) n DESTRUCTION (choose type below) <br /> n SOIL BORING# a OVERBORE. DIAMETER <br /> AWELL# SR- II aPRESSURE GROUT <br /> x•Other tPT-aSt�P-ri 3'AreuS 1. SP-IO GROUT SPECIFICATIONS <br /> , <br /> COMMENTS: ) CPT-AS' CPT tAxo+.dl. ft-S' : QZen-e SN4r4e Pri..J-S <br /> 3) SA- a An. '}..ika wen <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> I))LMONITORINGr j)HOLLOW STEM DIA.OF BOREHOLE f d t�0 MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA' <br /> a EXTRACTION a AIR HAMMERIDRIVEN CASINGTHICKNESS Std• Yd TYPEOFCASING #STEEL )PVC nOTHER <br /> n VAPOR n MUD ROTARY DEPTH OF GROUT SEAL f�1 f 59 t TREMIE TYPE TO BE USED: )I:AUGERS 11HOSE <br /> )jfAIR SPARGE)OZONE I�IJ PUSH POINT(GP or CPT)GROUT SEAL.PUMPED: A Yes nNo (NOTE: MAXIMUM FREE-FALL DEPTH IS30') <br /> 'Pr) ter, t.Irar <br /> n SOIL BORING p HAND AUGER GROUT SPECIFICATIONS Nt.f tem en'7`" HT ..a4 = Tr aro i /di0L <br /> ){;OTHER: 07- n OTHER APPROX.BORING DEPTH !A I $BOLTED TRAFFIC BOX or n STOVE PIPE <br /> CONDUCTOR CASING PROPOSED A/o (if YES,list specifications in comment section) <br /> COMMENTS: Or art+ ti v los - 0 rle­! <br /> s. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS A REEMENT OR ENCROACHMENT PERMITS! t.;!) <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 /> Countyrdinances, Rules gu ations,and all applicable California State Laws. <br /> Signed Title/Company <br /> Print Name �/1iFM 1 FCT Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: p <br /> application Accepted Date Issued uvdo 7 Area 5 <br /> :;rout Inspection By. Date]..�2-� ��LFinal Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS f CONDITIONS: tAmxJ5_ aj,"CJ:717 I / Et <br /> ACCOUNTINGONLY: AID# - FAC# <br /> PE CODES FEE INFO AMOUNT REMrrTED CHECK# REC'D BY DATE PERMIT f SERVICE REQUEST# INVOICE <br /> <75 - o sR#oo3b'�'/S <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment clot_ 9/30/02 <br />