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roc "IN. co pan Joaquin t ounty101165 31, 3 c <br /> Envir mental Health Department SITE <br /> 304 East W er Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> ,209) 468-344y rax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> o �c <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 Develgrn nt Title Chapter 9- 115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> I Od0 W Q w Ac£ /2cAp <br /> WELL Location 3c4crq EUA op Rrn tx,'f,-7k4cT--S£f..M Assessors <br /> �oss Street d t BHT Mt&E RD City Sy-oc.ICT+✓v Zip 9.Szl�/ Parcel# 071—050--15 <br /> PROPERTY c/o TwmeL qucKex" <br /> Owner RInIYX,CTRI}cT R� N SiTAddress22oO W. � �A City /4c��P�= Zip�sZw Phone# 2- �553�7 <br /> C#L"fV�_✓ 50`3 ' rt�fffr6LS jjLVJ� 71o�3`f <br /> C-57 Contractor C,aep�zx(�toYCRi'f7U�✓ Address t�iTL 3—�S�F City ROS�YILI�Zipg 7Lic# hone# -1161 E3 —22/� <br /> 3140 b6Mt:.fJ&VD p',9W G-Lr''Te&I.t# <br /> Consultant/Sub Cntr Pf}Nrcyt9ft1ECP1NiC/JC Address SU rrL (e)O CitywfST�R Lic# Zce4 Phone# 91� -371 -Dy3j <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/ BORING (CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> Other LivS 1 f i_ Teov A M1 z4TW6 GUl2 P�2fSSf(2£ � ��r GROUT SPECIFICATIONS <br /> Ix AA <br /> (i FLrm I M 1D.FLL (-1.G.FS R � fl <br /> COMMENTS: G'EwNs- 6-t2ot4-r AC-T�_k fN-CL&Tro.� 6F &yrfz4rA1' � <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING HOLLOW STEM DIA. OF BOREHOLE rr 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: NbNF_ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS o/ue TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR XM LID ROTARY DEPTH OF GROUT SEALd15 MINIAt(fiY( TREMIE TYPE TO BE USED: 0 AUGERS ,RNOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED:AYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Pett( 'Ji" 6--Mi, +5% <br /> %15 <br /> $".moi tift7� <br /> OTHER:Passstui 0 OTHER APPROX. BORING DEPTH �S j 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 1'V5-ow/1%,ty CONDUCTOR CASING PROPOSED 1V0fJC- (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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x �1�� Title/Company RAMLY ` TMC- /U CAL, 1UC, <br /> Print Name Date f0 L(� DJC <br /> DEPARTMENT USE ONLY <br /> nn <br /> SITE MAP IN UNIT IV FILE, ADDRESS: �1 p 0 I ( tn�� _ K C� <br /> WORK PLAN DATED: 64- <br /> Application Accepted B Date Issued 1 Q / O S Area l f <br /> Grout Inspection By Date 1, 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 /> �� � � $ �lTSR# <br /> �� �� c y5 �3 <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 />