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_Nk <br /> San Joaquin County <br /> Environmental Health Departm 1 :3;I,j SITE <br /> 600 E. Main Street, Stockton, CA 95202-3029 1�2hn ITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.01qft hd) <br /> UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE WgUIEP' - <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application s made in compliance with San <br /> Joaquin County Developmerl Title,Chapter -11"153 and the Standards of San Joaquin County Environmental Health Department. <br /> L c ti tCk�X� 4 Assessors <br /> EL 01 Ny ross Street city(j1A Parcel# <br /> T 411- <br /> P /5 2W- <br /> Owner- Addresfk _CitZfX166' Zig!5?'Lorie#"n�' <br /> t76 <br /> C-57Contracto4,T,l-,-�6L-te�evin'-fl,tl*ddress36, 2-(()mec-CCr c4_�i_m_W C# <br /> 7 "OPhone# <br /> Consultant/Sub Cntr 096.16-- Address / SikaLolu Phone# *7)6)(� <br /> 1211 Cit (Ahlic# <br /> GIS Coordinates:X y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ONEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 26ESTRUCTION (choose type below) <br /> a SOIL BORING# a C�VER-BORE. DIAMETER <br /> a WELL# ,TPRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS WL-A <br /> ,00NITORIN .9101LLOW STEM DIA.OF BOREHOLE_61:�ItAWULTIPLE CASINGS GMULTI-LEVEL WELL CASING DIA:2 <br /> 0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL 4rPVC 0 OTHER: <br /> VAPOR a MUD ROTARY DEPTH OF GROUT SEAL_7D �'�TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br /> ,5_SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED:>JCes 1Ng SNOTMAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS 7 <br /> a OTHER: a OTHER APPROX.BORING DEPTH A401-TED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASINGPROPOSED if YES,list specifications in comment section) <br /> COMMENTS: Ge,--A 3 (-,-, 0 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR FNX-ACH '( ISmt'clt 7�foi_p <br /> MENT 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 Iraws., <br /> Signed x 1A;4d,0,L Title/Companyr\ <br /> Print Name Date---I? <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> ' C>m <br /> WORK PLAN DATED: y 12�c b rjA C-t ry <br /> Application Accepted By2 <br /> _ I h1d AAA CC-L-N Date Issued /_Z�' -7 —Area62.1S <br /> Gfout-4i%p_td...'By_ lZate c <br /> Slz.-LQ?- Final Inspection By LN, __ Date <br /> Destruction inspection By Date <br /> COMMENTS/CONDITIONS: Y1 V/ 4- vaik cno, J�A tj" <br /> ACCOUNTING ONLY: AID# FAG# <br /> PECODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ::_ —.0 V <br /> 7- -ff <br /> S R# 6s c, <br /> C-57— WC=WAIVEP C-57 Letter of Authorization to Sign permit Encroachment doc— <br /> EHD 29-02-001 web <br /> 6/22/04 <br />