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0 46 <br /> San Joaquin County <br /> `s Environmental Health Department SITE <br /> w 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> F P 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 Development Title,Chapter 9-1115.3 and the Standards off San Joaquin County Environmental Health Department. <br /> 50,0-,r Assessors <br /> WELL Location L91S Vt40437VL Cross Street N 19ASvn <br /> City n Zip asaf33 ParceHF 'L(s��D0( <br /> PROPERTY r2.�r cit <br /> Owner Q�a.,t,(a�o stftk yAddress 36 NFI 9041 4i , City -%Ckk ^ Zip 5)-0Z Phone# �r <br /> C-67 Contractor C'.ASc_ u 17ri�k.� I Address S63Z Of&(� t c.trcr� 11 City-L a� Zip%-?'l Lic#jQS-10Phone# 4-6�o"II61 <br /> Consultant/Sub Cntr SI�r92=r,,Ulrmkaiu.•I Address3yi7-k--i �L City K. Lic# Phone# <br /> GIS Coordinates:X-C 3NX'3-'J."N ,Y ;'Iry,Township_ Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION (choosetype below) <br /> u SOIL BORING# %OVER-BORE. DIAMETER ba <br /> a WELL# 2LI a PRESSURE GROUT <br /> n'Other_ GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING THOLLOW STEM DIA.OF BOREHOLE rr 0 MULTIPLE CASINGS p MULTI-LEVEL WELL CASING DIA:_ <br /> u EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS Sct. t'tO TYPE OF CASING: U STEEL III B OTHER: <br /> p VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br /> u AIR SPARGE/OZONE n PUSH POINT.(GP or CPT)GROUT SEAL PUMPED: u Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> Q OTHER: g OTHER APPROX.BORING DEPTH D p BOLTED TRAFFIC BOX or U STOVE PIPE <br /> CONDUCTOR CASING PROPOSED(if YES,list specifications in comment section) <br /> COMMENTS:'()\Ixr�t\ " n,r.,,..5 rI+ MJ 3'9 (,30.C+ t•2U�f-4 k k, Sc. No(A1c lr-a1*+ w. !ku rte} <br /> benslj <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 ga2sn. ZkdAM) Title/Company 3A-c S�,C-A i S I),-S P <br /> Print Name 'jA Date f-t s'-ha <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By r - Date Issued / 20614 Area <br /> Grout Inspection By Date Final Inspection B Date <br /> Destruction Inspection By I AL <br /> COMMENTS/CONDITIONS: C�x cs r r t <br /> ACCOUNTING ONLY: AID# (tFA-1C# 2ooZ C) <br /> 1PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PER /SERVICE REQUEST# VOICE <br /> 2-21011 89 . 00 91 # <br /> C-57_ WC_-WAIVER_ C-57 Letter <br /> of Auth ' atio to sign permit Encroachment doc <br /> EHD 29-02-001 n <br /> 6/22/04 <br />