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� Q-SIN c � Joaquin County <br /> )Environmental Health Department SITE <br /> 4F N 600 E. Main Street, Stockton, CA 95202-3029 <br /> MITIGATION <br /> (209) 468-3449 Fax: (209)468-3433 Web: www.sjgov.org/el'id <br /> FI L Well Permit ApplicationE Up Was <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED <br /> Application is hereby=madetd 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 9-1.115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> SA ty -T G A 0 t'i N Assessors <br /> WELL Location ? Ws i' E Ek AV E. Cross Street t' E E City i r`{ t�(G I$ Zip a,.4%2 Parcel# <br /> PROPERLY t <br /> Owner i-�i l. ( f f"f f i1 G t t, Address 't L .:i k t i 5 A Y i= Ciiy 5 i t%�f €iii Zip �i`v)Phone;r <br /> C-57 Contractor ` 4 tr:r t t `v� ti! Address% `i` ' t l:ft�fel 'i err+l C � Cityirt G <1 WilZipFSl Lic#F 4 �' Phone# <br /> Consultant ISub Cntr=ti Er,P t_ra€Lir ;i F;E_. 1 t G Address t" i G ..I S-- City I Iz f°( Lic#�' i �° Phone# E I�° ( t E• 5 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) I?DESTRUCTION (choose type below) <br /> 0 SOIL BORING# I OVER-BORE, DIAMETER Y t 14 1,I{ <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: i) 4i P e/i i s t% Ci F 31'i t t!4 R l Eel €,- W e LL 5 -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> C MONITORING I HOLLOW STEM DIA.OF BOREHOLE J! a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: --- <br /> 0 <br /> _0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 'st�T TYPE OF CASING: 0 STEEL I PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 'I t t I TREMIE TYPE TO BE USED: 0 AUGERS p HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes I No (NOTE. MAXIMUM FREE-FALL DEPTH IS 30') <br /> p SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 1�UVt- C.t-M E N I <br /> 0 OTHER:_O OTHER APPROX,BORING DEPTH 4 5 - �5 1 _I BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NA (if YES,list specifications in comment section) <br /> COMMENTS: E S t RVC, Iv,It-4 U � � r0t C-N €T C I:I I�. 't�' E LL 5 <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 /> Signed x �+--�Ii e°� •^-.�'— Title/Company : t �i�! !`IE f it liFtr. tI�IIE�f�1. II+i4, <br /> � � F <br /> Print Name C S I n I } Date <br /> 6 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 2.2 2 E we-bp-n- Ayen tl t✓ <br /> WORK PLAN DATED: SE 12++111 btl 19 2008 — d <br /> Application Accepted By Date Issued 1() -241-08 Area ids 1 <br /> Grout Inspection ByY f Date !!- `0 Final Inspection By�� tit /Fll . Date <br /> Destruction Inspection By V, <br /> jr'I n Date <br /> COMMENTS I CONDITIONS: j - <br /> ACCOUNTING ONLY: A1D# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3502 461,00 QT 3 ?S, 00 2406 10�Is� o8 SR# O0s's qe ! <br /> 3503 315.00 <br /> C-57_ WC^WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc. <br /> EFID 29-02-001 web <br /> 6122/04 <br />