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OPQUIN dC San Joaquin County <br /> o 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.orgM MAY I I PM 121JAT IV <br /> Well Permit Application S.4 pp <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUE 4,E � 4 T IRI[)EPtl N T i1 E PJ T <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 t e tandards of San Joaquin County Environmental Health Department. <br /> 5 d r A•l�` �C� �' i+ A/N����p�J Q ci Assessors <br /> WELL Location ! U✓ (J �Z Cross Street �aK�S �c�• City l(��/�t7 Zip 1 Sad© Parcel# 613- as- 06'7 <br /> Owner LDr1I G✓/IL'TlVcp,P1Sp�,/ L PC Address /0155o KK 6OPERTY ��}, City 6d6! «1 eZip f 5ZS8Phone# <br /> C-57 Contractor (Y,/"/`� a_11<0f,)' , kZAddress 100r-,�JA�i Iv&y�X, 116 City S!�'�-ON Zip YZy/Lic# 7x010 Phone# ft- 17'I <br /> Consultant/Sub Cntr I /f lioiceldel- Address r 3 s�/ [Nd-/1� City 5�k{v r) Lic# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> WELL# MW' l , /`LL+)'' MhJ' 0 PRESSURE GROUT <br /> 0*Other ' GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING X11OLLOW STEM DIA.OF BOREHOLE�Sf' 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:a___ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 4#0 TYPE OF CASING: 0 STEEL XPVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Ya�eP� TREMIE TYPE TO BE USED: )(AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: gYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS` <br /> 0 OTHER:_G OTHER APPROX.BORING DEPTH (00 0 BOLTED TRAFFIC BOX or XSTOVE PIPE <br /> CONDUCTOR CASING PROPOSED N (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.. 111-1?IA.,Signed x ( � i(� /c Title/Company&/ eC�6b ��01( ;IW,-/' <br /> Print Name 'Z''1-0 A", Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORKPLANDATED: 3�7.t (�<o - CU12G✓ Qet`� �2uGL oL.stocam, �' w c,.. (-I'a ��� at <br /> Application Accepted By <br /> I (\nip `��- Date Issued 5- z�-/U b Area 197 <br /> Grout Inspection By//K Date :�- 3r o(o Final Inspection By 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 I SERVICE REQUEST# INVOICE <br /> SR1100g6-7q� <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 />