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FILE COPY <br /> oq.�tk J0 San Joaquin County <br /> z. y Environmental Health Department, ;,. SITE <br /> W { 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> -:`• (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/CPM 1• 48 UNIT IV <br /> c . 0 �'c ` B <br /> Q�rFi;R� Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED U� <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 /T� /�Sr.•r.-fir /frr Cross Street��f Y� City •����rf« Zip ryssj� Parcel# <br /> PROPERTY <br /> Owner C.w« ��`��AS Address X00 .4P41]rZ WJ /1, City r!<` rfc..i T Zip 11.ZSA?Phone# <br /> C-57 Contractor p,!!V S/Wt�a'/�' A/ddress/'j�Gt7 S Say ST City���Zip ff��Lic#6 ,397 Phone#5/ 03?— <br /> ��� •f City �r P z Lic# c�5`P`f�� Phone# <br /> Consultant!Sub Cntr Sf ccs f:.f�•��.•��.:•:� Address ��'��•-r ��s�� , <br /> r <br /> GIS Coordinates:X Y Township Range Section_ <br /> WORK TO BE PERFORMED: <br /> EW WELL/BORING (CPT/GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) []DESTRUCTION (choose type below) <br /> 'kSOIL BORING# (0 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0.Other GROUT SPECIFICATIONS <br /> COMMENTS: -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE ;?' Q MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:------ <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL U PVC 0 OTHER: <br /> []VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL -J—C'i x TREMIE TYPE TO BE USED: 0 AUGERS HOSE <br /> 0 AIR SPARGE/OZONE XPUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes oN/o (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS /'/e, G�lrlf/r/T <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH SC Al'-x 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED /l�� (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 Joaquin <br /> County Ordinances, Rules and Regulations,and all applicable California State Laws. <br /> Signed x �/� AZL11AAs Title/Company fesIr <br /> Print Name <br /> ///c%4r�,/ /ficr Date <br /> r <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: AX))l e& f <br /> WORK PLAN DATED: 0 i •o <br /> Application Accepted By Date Issued �� 2 7' Area d6 <br /> wl <br /> Grout Inspection ByDate 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 /> 160-16fsR# 0 l0�/ <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 />