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*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 /> /FOR Well Permit Applic C �7 I'M 4:.39 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR 5I'�ONI,DATE ISSUED <br /> xDl, O4 4 i CtJ <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install l�y¢{{r rg�ypr} � hg��ilication is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San JoagWfL. .4Mflp O�hprnr� I Department. <br /> 1 �n� Assessors <br /> WELL Location 9318 t. I�zas) PP,L� Cross Street E. �b�Iw. City Sip i5ZI5 Parcel# Osi-loo-?S <br /> PROPERTY E"m000 II Q (� <br /> owner W4,L PW_ PIa4Address `/407 E VfaLf�co ��. City ?Fc-L+{ ,.. Zip 457t5'Phone# f7fA�g3f-LSSU <br /> C-57Contractor I P:oIv Address JIM &ii,e ko , Clty &c- - Zip SSa Lic# z(. Phone# 701 Y-9d/b <br /> Consultant I Sub Cntr A&-E= Address 83'1 City' 4M Lic#Gfso Z2'] Phone#/Zo4)467- i� <br /> GIs Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> g I EW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> g1JELL# I 0 PRESSURE GROUT <br /> 0"Other GROUT SPECIFICATIONS <br /> COMMENTS: I wicn— lj I,r, 9r 6941 <br /> TYPF,OF WELL INET LATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ONITORING OLLOW STEM DIA.OF BOREHOLE S" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: Z� <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS St I .SIO TYPE OF CASING: 0 STEEL IVC'' 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEA Sr `, TREMIE TYPE TO BE USED: ff<�GERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: fl-Vas 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> O SOIL BORING OHAND AUGER GROUT SPECIFICATIONS 7v� III Pat-la� l'a <br /> 0 OTHER: H 0 OTHER APPROX.BORING DEPTRH Ql�-OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED no (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 Jo � <br /> County Ordin nces, R sand Regulations, and all applicable California State L/^aw11s. <br /> Signedx TltlelCompany �Ealo -st F <br /> Print NP Ja G�ao.+-tam Date -O <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: y 4 o --� k)a (r o Ro-f . <br /> WORK PLAN DATED: R I a- 10 G <br /> Application Accepted By Date Issued 1 Z/I I 1 OL, Area {7 2-1 <br /> Grout Inspection By 141 1 w.c Date tth If fp& Final Inspection By 1.AJ4-t� Date (z_114/az <br /> r— <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3 S- I sa 2`19oI U C <br /> 35b lzItt(o,6 SR# <br /> -,moo <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permitZ Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />