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`-San Joaquin County `'w <br /> 2 Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> cQ Well Permit Application 2005 Jul: PM 21 - <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN JO A QUIN COUNTY <br /> ENVIRONMENTAL <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is r6ffi &C!*rI Fth7$ CNT <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County <br /> ► Environmental Health Department.A <br /> Assessors <br /> WELL Location 3012—CAS - [A�f(00 Cross Streeto��Q yvc � y Sty ti Zipc1S244Parcel* <br /> PROPERTY 1 <br /> Owner ky.L my- (4s- -NAelZ Address 45t)2 �Q.KXpC t-e.kCity � t�st� Zip IW Phone# j7_7-4,91o_7__ <br /> C-57 Contractor l.0.`.:L�11e. V(II hUtQ// Address 3U)Z()uVt2—(),rje_ Cityn 1 1 C ip'I5�l&# Lj5jD Phone# 9� 6 -(I q <br /> Consultant/Sub Cntr Agtn MC� C�LObtUj/17N Wt ess f6Y7 SLAAU City_S}��v Lic# 227 Phone# 467(4U4, <br /> GIS Coordinates:X 'y Township Range Section <br /> WORK TO BE PERFORMED: <br /> EW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> ELL# 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING '5 Q LOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: Zv <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS Sri.4D TYPE OF CASING: 0 STEEL )5:tVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL+5 r TREMIE TYPE TO BE USED: `'AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: I$.Yes 0 No (yOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS ` ter I <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH :70' BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED Ac�' (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 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. g <br /> Signed xp Title/Company �Qpq bT <br /> Print Name rDate _V1 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADD ESS: (� <br /> WORK PLAN DATED: I S <br /> Application Accepted By Date Issued_ 16-SAre A+Ma_� <br /> ` r <br /> Grout Inspection By Date 7 Final Inspection By r Date <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 /> �Io0 . SZ '*7 ( SR# <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 />