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�oP• uI. Co *San Joaquin County <br /> 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 UNIT IV <br /> o �/PoRN. Well Permit Application WON -1 Pirhit 39 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ;GUill COUNTY <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. �wIPP1 Lr?i�TdR N compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmel �. I�rAWT HENT <br /> / I Assessors <br /> WELL Location ��D� Crass Street Wx �). City <br /> p SZIS Parcel# hS�l-(oo-S@ <br /> PROPERTY �1 I <br /> Owner EnvsF L9�nnw.cc n� Address H07 F.tAf,) Pc) City—S+ cc Zip aSllS Phone# 43)-2S5o <br /> C-57Contractor M;Ijej1 P,',I);m r�Address 74Co City_fLfL�,- Zip v3 Lie#6)zrol7 Phone# O <br /> Consultant/Sub Cntr AGE Address &g0 Ku- City4Lic# Zj Phone#(u•Y)yt,7-f-G, <br /> GIS Coordinates:X ,Y Township Range Section <br /> WO TO BE PERFORMED: <br /> 'g'I EW WELL/ BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> 'a'WQQALL#BORING# a OVER-BORE. DIAMETER <br /> PRESSURE GROUT <br /> 0"Other GROUT SPECIFICATIONS <br /> COMMENTS: 3 i,..ells +c 1e'j bkr 3 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS p <br /> a MONITORING OLLOW STEM DIA.OF BOREHOLE V a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 2 <br /> a/EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS Sr L-Nr) TYPE OF CASING: O STEEL B4C0 OTHER: <br /> V APOR 0 MUD ROTARY DEPTH OF GROUT SEAL ) 4 q I r TREMIE TYPE TO BE USED: R'6GERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: res 0 No (NOTE: MAXIrMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS 1Y[/II }I ���re f <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 30 (ons tf a0LTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED ,.ro (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 Joaqlu � <br /> County Ord'nances, ules and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company (�eo� s� �� <br /> Print a � G�.a��+wv� Date I2-(✓'YJ t¢ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: q ND 7- WOV'(-el (00 f4C4 <br /> WORK PLAN DATED: Sf of, <br /> Application Accepted By (.(.�..,�nnt e.� Date Issued I s I I t /o& Area 4 21 9 <br /> Grout Inspection By Dale lzoG Final Inspection By bL�-r,,,.,.�� Date [s.ri r�eG <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 /> 35at j%".00 (�( SR# `-lc ll5 <br /> ".ov <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permits Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />