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CdA u►ry rp San Joaquin County If',)IrL <br /> (i '1'��'i�,`�/I� <br /> Environmental Health Department--- ��,� U SITE <br /> 600 East Main Street, Stockton, CA 95202-3029, MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd 2007UNIT IV <br /> ,Fo���4 Well Permit Application `I1JRro`r ,'�ISERVIC�L� <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED CES <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 /> WELL Location E 33 E.U/c1rr / Cross Street /� 7 City 1 G)d / Zip 9��/O Parcel# bV 3���'Jr 5 <br /> PROPE `' h / /1 <br /> Owner J wick Ke wx Address 41S-7/ /'CfSI Cit y&I,_4 Zip`/'7Phone#� 377-S�6 �/ 7 <br /> C-57 Contractor SL�iL �Sr Address �>7j/(1,'/y C►�¢iL L/ City I1�IGL2S�Zip 3i� Lit# ! 22 UPhwee##�7 / <br /> Consultant/Sub Cntr A J� —IZ 614 Address/ y--- d, tAj 51 CityL-rV11� Lic# Phone#q � <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/ BORING (CPT,GEOPROBEl HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> m SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: SOS f?L>I2/nJ6-5 !7) c52 Q F <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 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: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL.))' C-1-�, +- TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE f PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 1 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS h//Zr 1fT CE7rt E�/T <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH o2 D rT 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> J, <br /> CONDUCTOR CASING PIR-OPOSED �(if YES,,list specifications in comm nt action) <br /> COMMENTS: 1 � `�� ; <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 Or " antes, Rules and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company 10104j'�Z-<< 01.4e466772 <br /> Print Nam �c r'C�r>y �G�SSc'l� Date �� v25 —Q Z <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: .633 J«-}oy R-cJ <br /> WORK PLAN DATED: �- <br /> Application Accepted By Date Issued t 1 S I D Area Z 1 <br /> Grout Inspection By Date It la10 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 /> 2101 g�.oa $foo (�Q 1�11�/0� SR# <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc_ <br /> EHD 29-02-001 WEB <br /> 9/11/2007 <br />