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o� San Joaquin County <br /> '410 <br /> �� � � Environmental Health Department SITE <br /> CA 95202-3029 <br /> 600 E. Main Street, Stockton, MITIGATION <br /> tar <br /> • (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/ehd UNIT IV <br /> \og4�MP/; <br /> 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 of San Joaquin County Environmental Health Department. <br /> .,-'/- Assessors 2� <br /> WELL Location 3z4 Z S•L—I Ll%ciAP S-tyeL ' Cross Street V Ave City StDCA:%tl! Zip�1S-?Xo Parcel# 1?7 OZo <br /> A��, (3�0�sus'—Y��CA�cbw�'llPr <br /> PROPERTY L �� l VAI G��--�,,/ /'�,,� t� �j�J`f f�/ LI4�1 <br /> Owner4.0\1e A&i/ICiAddress � City SG Zip {Jl�ilyPhone#i(�'/ � �7� (T M� <br /> qSD tti i Lic#NS5'76SP <br /> C-57 Contractore) - ll Address Cityjj�—Zip Phone <br /> Consultant/Sub Cntr %lior WS C-lnVt. Address I'ifMn � itY Lic# 3_6 Phone# <br /> GIS Coordinates:X-120#141"L•Sb t ,Y:W ����" ,Township Range 1: Section <br /> WORK TO BE PERFORMED: <br /> ,)AEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> *Other !I GROUT SPECIFICATIONS <br /> COMMENTS: <br /> 01 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS It <br /> � <br /> 0 MONITORING i' OLLOW STEM DIA.OF BOREHOLE ,MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING PIA:: <br /> 0 EXTRACTION 0\AIR HAMMER/DRIVEN CASING THICKNESS �fYPE OF CASING: 0 STEEL KPVC 0 OTHER: <br /> XAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL��SkV —TREMIE TYPE TO BE USED: AAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes�y��&No (NOTE: MAXIMUM DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 6E All "I' lad S� ^�f iI'� <br /> 0 OTHER:_O OTHER APPROX.BORING DEPTH A5 0 BOLTED TRAFFIC BOX or ASTOVE PIPE <br /> -C� k CONDUCTOR CASING PROPOSED (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 /> 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 /> l <br /> Si ned x f/ /lam �— Title/Company �1P�V 1�U�It e <br /> 9 <br /> Print Name �� f "►�vt I Date A 9 <br /> DEPARTMENT USE ONLY <br /> PAYMENT <br /> SITE MAP IN UNIT IV FILE,ADDRESS: nrr`C41 f Gn <br /> WORK PLAN DATED: <br /> 7 �. �lS2-v Date Issued -7,423/OUL 007 Area <br /> Application Accepted By <br /> Grout Inspection By a4('� ' Date �OS�� Final Inspection By <br /> Destruction Inspection By Date ENVIRONMENTAL <br /> HEAL' <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 /> i/o g I y p. fe a 7 SR#L)C) > I y" <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001web <br /> 6/22/04 <br />