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ioPa San Joaquin County <br /> Environmental Health Department W�� / � SITE <br /> o\ <br /> e: ai <br /> `� A<< 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> `t <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ei�-I' •� LUGS UNIT IV <br /> Well Permit Application E VIRONIOEN1-I.IEAt <br /> Ip <br /> RMi7/SERVICES <br /> NON-REFUNDABLE PERMIT EXPIRES t 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 /> WELL LocationG 77 2 ZlOw/4+ /N Cross Street —Lou(! City HZip Assessors <br /> TParcel# —9e eo-o<R <br /> PROPERTY_ /� / J <br /> Owner (90 Address �rc 77 7 1711�c�//y�4 City iv Zip S�3OPhone#yt0�(- Q��eZ �11 <br /> C-57 Contractor /t Address p.�0 &,,e City �f" Zip S S�Lic#6f6 VO7 Phone#l�3/3 <br /> Consultant/Sub Cntr �cwr�fi;�rw+,r✓�AddressRfff/Ou ft.Lfr.;/s City Flefn U Lic# Phone# <br /> GIS Coordinates:X-37 V Y Township l Range / <br /> g (D � Section 3.S <br /> WORK TO BE PERFORMED: <br /> ,"EW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> ,SOIL BORING# , /I/ Q 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <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 /> 0 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 9YusH POINT(GP or CPT)GROUT SEAL PUMPED: fes 0 No NOTE: MAXI UMFREE-FALL DEPTH IS 30') <br /> P-�901L BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> /! / CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: GPo liohe �� /040ree <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that a e pre red this a plication and th a work will be done in accordance with San Joaquin <br /> County Ordina s les atio nd al c e California State Laws. / <br /> Signed x ;/ Title/Company Ca; �4/e Ilea f/s <br /> Print Name <br /> 2L9016441" Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: / <br /> Application Accepted By_ Date Issued �r '2�/,�> Area q',3 <br /> Grout Inspection By Date Final Inspection By Date Z /d,& <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/SERVICE REQUEST# INVOICE <br /> moi/ /' „ r r SR# <br /> C l� iz. , <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 />