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04 U. ti San Joaquin County <br /> a <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.sigov.org/ehd UNIT IV <br /> 0 <br /> `'��R`'� Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELLLocation IOZ So.,t1n W:I%UH W1 4 Cross Street Markk+ St. City 5}ycI<+on Zip Parcel# <br /> PROPERTY <br /> Owner A5g1^4r Address (n61 Wavle- AVB. city,/A Ocle%+0 Zip 49751 Phone# <br /> C-67 contractor V S W Dr;11:�y Address 100 f;F+ti sl-/ee + ctys 4w Zip 4S(oglLic#'710104phone# 4(b-111- 9/00 <br /> Consultant/Sub Cntr (rro -t a rd A�aIYGP.ddress VI I`l AAAI- $�. CityEt fgilP� Lic# Phone# <br /> GIS Coordinates:X 'Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> *NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) E DESTRUCTION (choose type below) <br /> a SOIL BORING# a OVER-BORE. DIAMETER <br /> X$WELL# MW 1-1 C. aPRESSURE GROUT <br /> a Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS r <br /> MONITORING a HOLLOW STEM DIA.OF BOREHOLE tZr/9+1 -MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:_Z <br /> a EXTRACTION u AIR HAMMER/DRIVEN CASING THICKNESS Snk. '{D TYPE OF CASING: �TEEL PVC G OTHER: <br /> a VAPOR ILMUD ROTARY DEPTH OF GROUT SEAL 10 (o TREMIE TYP TO BE USED: E AUGERS ?POSE <br /> g AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: )i Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> n SOIL BORING aHAND AUGER GROUT SPECIFICATIONS Nerh (¢weal- - ovi ir.,..... serf>.t 4, (0(o Fee f 67- <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 1_LO ' BOLTED TRAFFIC BOX or E STOVE PIPE <br /> S/$ CONDUCTOR CASING PROPOSED 2 S (if YES,list specifications in comment section) <br /> COMMENTS:-(D— d;u.--c.�-' Cw.��c�� Gw,��,, wltl IK i�41'411t tt ♦og 'Lap fl— df 91) r-eef - <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 Regulation all applicable California State Laws. <br /> Signed. dd Titie/Company StA.�F �e0�oy�f} /�ra...nd 2l�a A..wlyf•S <br /> Print Name w2.Z� Date �/30�tl (7 <br /> DEPARTMENT USE ONLY — <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: 2 /Decee;46" 20O <br /> /V s / <br /> Application Accepted By 'Ile Date Issued !�" '-! Area l Z`/` <br /> r3 <br /> Grout Inspection By Date 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/SERVICE REQUEST# INVOICE <br /> 3 >I 339 <br /> 35r SAosr g 2» /(102! 7 NYZ !f r,%UG SR# L10 t�(o`{p <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6122/04 <br />