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an Joaquin County SITE <br /> nv-twhmental Health Department <br /> rC_--�VBeast Weber Avenue, 3rd Floor, Stockton,CA 95202MITIGATION <br /> 209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> • a 2 3 AN Well Permit Application FILEIW <br /> ENVIRONMENT HW-�FUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> PERMITJSERVIe work the work <br /> Application is hereby made to San Joaquin County9 11 5f3 and the Standards of San/ r install County Environmental l Heath Department Assessors <br /> in compliance with an <br /> This a <br /> Joaquin County Development T P Assessors <br /> � <br /> 3 �ZSr f�h� Cross Streetr . City 5IB t 0 Zip ft.�O Parcel# tI70�03 <br /> WELL Location2 CTT <br /> PROPERTY # C`I �D. &X 3ZYJ City Zip �M Phone# <br /> tM <br /> Owner Iv1 Address p r� //++������ -,qr <br /> PG G 33 6 City[�,rk5k---ZiplLlLic# jl�� IPhone#ZQI 3 �� <br /> C-57 Contractor Wo 1i-n Address n/ A� /� } -L <br /> Po-IYVt/Te Cit '`�WCI `4 Lic# Phone#�1 519-77z- <br /> Consultant/Sub Cntr_r"L.t G Hs�x�i(;tAddress 1�1 TVIe- y <br /> GIS Coordinates:X <br /> Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> n NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) T of ER BORE.I DIAMETER a type below) <br /> Q SOIL BORING# gPRESSURE GROUT <br /> 0 WELL# GROUT SPECIFICATIONS .2 ' 6 6/r�c�i f Cevnt.►� <br /> 0*Other <br /> COMMENTS: kb-7%A-0(6n 3 IM 1,6 1�or IIS A4 w I <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING n HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR n MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> n AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') Z <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: It <br /> CA <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. `t <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. r <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin S <br /> County Ordinances, Rules nd Regulations, and all applicable California State (Laws. / <br /> Signed x Title/Company D►7 "Ok ryV r I R -r 01A 4V ate" <br /> Print Name....- s2iA,V1 A'k U 6 YV1Date Z 2Z O <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 3302 wesi Lay;I e <br /> WORK PLAN DATED/: <br /> Application Accepted By Y ie,+or�a L. Me.C,a)-+Yt eu _Date Issued 1 -4 - 10 4 S Area) I <br /> Grout inspection By ViC� id. P t'lfYtl+n Date I 2- /d Final Inspection By Yi lfarlm YIMe& Date g-/b <br /> Destruction Inspection By ' -f r;d Date /- , - /O <br /> COMMENTS l CONDITIONS: +' r• - <br /> ACCOUNTING ONLY: Ala# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3502 Go.00 <br /> $5 <br /> 0 <br /> 2 345.uo 1 405- 0t) 05-734r1-y-/0 SR# 00,90 76 <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 />