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ill (o '!".� an Joaquin County S <br /> 11 /�l fid,T - <br /> N Environmental Health Departmt b ; SITE <br /> 304 East Weber Avenue,3rd Floor,Stockton,CANT(71 S 20 p5 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: wwvEA{�vgf(hd UNIT IV <br /> S�/FORa` Well Permit Application PERh'1T1]/G ' / IFA'rlj <br /> RV,I��S <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 /> Asessors <br /> WELL Location a,$U 1 lV- W eill AC Cross Sheet A41p1o a City zipclsaugPascel# l <br /> PROPERTY ArnQn'-,&V') fr "Ia1d01 <br /> owner. M i l fti c lir Cv ..Addrels d.9O 1 N- (J[C L "AC City S40[k 1u" ip y6/a(;�.Phone#6 flq 4/// <br /> /] /400 S J- 63 3F*- <br /> C-57 Contractor y_ /'e G/Sl U n Addressk c City pi:, u Phone# {�/U .�� -LIS <br /> Consultant/Sub Cnh MACIFC Address S4Lr1yl City�PQrW4.141-Lid Phone# 7G2 -. <br /> 2y� ;2Uu <br /> ( w-4 k,+ww'f-S .IC 3U <br /> GIS Coordinates:X"1}1• a!8 'y C/ Cl ,Township a r/ Range Section I('J <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPGEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> ff-SOIL BORING# ?J I f/ 0 OVER- ORE. DIAMETER <br /> 0 WELL# a PRIES URE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: n 2 e f S <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE_ u MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASIN : 11 STEEL 0 PVC 0 OTHER: <br /> n VAPOR u MUD ROTARY DEPTH OF GROUT SEAL —TREMIETYPETO BE USED: 0 AUGERS 0 HOSE <br /> a AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes p No (NOTE: MXIMUM FREE-FALL DEPTH IS 30') <br /> IXSOILBORING 0HAND AUGER GROUT SPECIFICATIONS <br /> JOTHER:SV j_-t y(_ g,OTHER 13 r/t 0- P 4)`APPROX.BORING DEPTH I S^ (j(�n BO TED TRAFFIC BOX or B STOVE PIPE <br /> CONDUCTOR CASIN PROPOSED ftl C� f YES,list specifications in comment section) <br /> COMMENTS: Q4/ r O r 1'r�rti.L ��/ p11 Y[ ' ��[)Cl 0(1 I <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 'lo (- Title/Company p <br /> Print Name UIC6Cfm.r..1 Dat 1 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By. Date Issued /O �/ T /OS- Area <br /> Grout Inspection By V Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> CX? Lj 3IS3 10//qloj I SR# 43—M <br /> C-57_ WC -WAIVER_ C-57 Letter of Autho Izati o sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />