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man Joaquin County _ <br />Environmental Health De artmen "ITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/eyfC 9 2004 UNIT IV <br />Well Permit Application ENVIRONMENT HEALTH <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEBERMIT/SERVICES <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 />RA <br />1 Assessors <br />WELL Location OQ'iapd Grar%ji ne. l A Cross Street TOSTe- City r&L Zip15310 Parcel# <br />PROPERTY <br />Owner JT S• or" aAddress ay�00 Tose R k City 1`r~G Zip S3 4 Phone# $35 -G5 q 9 <br />C-57 Contractor cm r-O.S e. Address 3%3Z ()Me(- C IMI C City co �Ie�a Zip9574ZLic# 711510 Phone# qI`' (0 33- 1164 <br />Consultant / Sub Cntr AGE Address ql-7 Shaw City_ i' Lic#( 9O.Z27 Phone# 4407-I00(o <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />D NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') ;'DESTRUCTION (choose type below) <br />a SOIL BOR-Ttv G # X'OVER-BORE. DIAMETER 8 <br />)(NELL # Mh/- 1Y. L , $ D PRESSURE GROUT <br />a "Other A GROUT SPECIFICATIONS r.I 941 b SrcK <br />COMMENTS: 0Vtrn r3� 110 +'0i-,kDlta�� bac.k�ANW t�. C r�ehi �QFFS.�� We 11s) <br />T"PE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />)kMCNITORING a HOLLOW STEM DIA. OF BOREHOLE_$ a MUL T IPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br />a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC a OTHER: <br />D VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS a HOSE <br />a AIR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes D No (NCTE: MAXIMUM FREE -FALL DEPTH 1S 30') <br />a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br />a OTHER: D OTHER APPROX. BORING DEPTH BOLTED TRAFFIC BOX or a STOVE PIPE <br />C CONDUCTOR CASING PROPOSED JI <br />(if YES, list specifications in comment section) <br />COMMENTS: Encroa. iKe"% i, 7ro"% Cl> y O � Yra�Y I 110L-1. IAA I -i(­JI-A.. ^t A," - <br />row4va t wa.f-er <br />NOTE: OFFSITE EORINGS REQUIRE ACCESS AGREEMENT R ENCROACHMENT PE --ITS. <br />43 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />I hereby cert' t I have epare this application and that the work will be done in accordance with San Joaquin <br />County Or 1 and ions all applicable California State Laws. AGE Signed x Title/Companyhge mn - �O r AGC.. <br />Print Nam \,er Date I Z 'j - O `i <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS:_ _a K2 C) <br />WORK PLAN DATED:_ ct <br />Application Accepted By Date Issued 6010 y Area -'6Z / <br />Grout Inspection By 1� 1/Inn�'G rn Date ZFS C Final Inspection By Date / Z <br />Destruction Inspection By Date <br />COMMENTS f CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />3' Z- <br />ov <br />21 Ln 3 <br />Ld <br />! o or <br />SR# W p 6 3 <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit cIi c <br />EHD 29-02-001 O <br />6!22/04 ItA 0 10 3 � <br />