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ooaV!^y. San Joaquin County W ��� V �U <br /> N o< Environmental Health Departmen�j16'� SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 912 0 2006 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.si*904W ROWENT HEALTH UNIT IV <br /> F0P Well Permit Application PERMIT/SERVICES <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 /> WELLLocation tU -1 Cross Street LOttA,56 Q.YLCity zipxParcel# 1931 <br /> 931 E!2Gq. <br /> I <br /> ck- <br /> PROPERTY <br /> -Q <br /> Owner J. cel- (.,Q. Address <br /> gq �'I <br /> l Le-77,7 �W OV3 to ajjj kjCity CakC O—Zip 652; hone '2�1 <br /> C-57 ContractorG(e4'Q 1)(111,rc�-Y�Addr�ss �I-(OWL City ( 7_ZirPW Lic#YBS <br /> --k&Phone#tq I <br /> Consultant/Sub CntrIS�Q�(A,l• f r n5ul{5 .Address ZU W MOiy7 S-- City Re 1U Licn# Phone# !-Z 35 <br /> GIS Coordinates:X�33gjL4IL.-74 ,YZI I(p(P(j-+.L4Gj ,Township T�. > Range (2'&E Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> 11SOIL BORING# Eb--4-b .411 Et3-AP 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0"Other GROUT SPECIFICATIONS <br /> COMMENTS: ll�D �VJC4(10W S(�,( 6orinc"5 A'D Qcouindwaw-r <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:------ <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE fPUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 1.)Q(, + C,,e,Vi eA 4- <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> n CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: Q�P.atona( ",er QS)QI L-W o'1aj:rU1 ?--urA r(-1 SEAQ C-0n40C*: G4ey-C M,e:0���1 I a,)Pi-o 32,91 <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 OrdinVices, Rules a egulations, and all applicable California State Laws. <br /> _ , <br /> Signed x \ Title/Company ` 2y' i pr nG,rt�er /U�(✓1Q I jC5 �GYISLt.( . , <br /> Print Name W 1 Al i o-m aLq V 0xn;'E-' Date -71I,6 I was <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE A DRESS: <br /> WORK PLAN DATED: (o Jlo�U LP <br /> Application Accepted By K. \ Date Issued W2-` 0 Area17 9:2 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: L.> Ca Gtr <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> /7aI SR# �y i <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 />