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FILE PAPP RE CIE !E0 <br /> Ul San Joaquin County 1 5 `J10 <br /> s Environmental Health DepaWfiA�irrifA1f_NT LEALTI-� SITE <br /> j 304 East Weber Avenue,3rd Floor,Stockton,d-15,240"E_R�,11C[j MITIGATION <br /> (209)468-3449 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> UNIT IV <br /> 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 /> Assessors <br /> WELL Location (. "4:G ?A&A to Oic114t0 Cross Street%ye1AA`41L5'V4LC1ty SkOC.L-1-011 Zip Parcel# 13�o�y50 <br /> PROPERTY <br /> Owner <br /> PROPERTY. <br /> C1.aPtvl Address \ui3 ti' fdtkt&tN' Cltys'-o0�t-kftZip 'J5Z03 Phone# <br /> C-ST Contractor ��e D-.t� Address 550 1kOuj e 6� . Cityl)'{4�tIZ ip 54s�3 Lic# Phone# !Z'5--3 t3- <br /> Consultant I Sub Cntr 00SV"CC So IVfiov�S Address "LIS i .S0.0\r ly CityC.oW Lic# Phone# R tt'o-:7 6o-357'� <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL!BORINGCPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> `SOIL BORING# _5 0 OVER-BORE. DIAMETER <br /> WELL# 0 PRESSURE GROUT <br /> *Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFI ATI <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLEZ N/A TYPE <br /> CASINGS 0 MULTI-LEVEL WELL CASING DIA: RI <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS N/Jr[ TYPE OF CASING: 0 STEEL a PVC D OTHER: <br /> VAPOR a MUD ROTARY DEPTH OF GROUT SEALLTW/�A' TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE USH POINT(GP or CPT)GROUT SEAL.PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING p HAND AUGER GROUT SPECIFICATIONS n ta-r Ce%%&ew& <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH S 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED 10 (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 Ordi es u s lations,and all applicable California State Laws. G <br /> Signed x Title/Compan VY }"✓0 � ``�e III Y75 <br /> Prins Name <br /> (�1 S'�U'��1�( ��169� ( Date S1 KIL5 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: /7166 YvLn1,, � o -Lo P 5� ,�CWW62 C 3 <br /> WORK PLAN DATED: �Q �� _ 2V 0 <br /> Application Accepted 6A_��� Date Issued Area 91 7 <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 /> o �S SR#00 (oci <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 />