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,an Joaquin County <br />rl-m� <br />FRWC vironmental Health Department <br />600 E. Main Street, Stockton, CA 95202-3029 <br />►x(468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />SITE <br />MITIGATION <br />UNIT IV <br />RWell Permit Application <br />EWIRONNIE-NT HEALTH <br />. pp <br />OCOA�IT��S�'ft0REFUNDAB LE PERN1117 EXPIRES' YEAR FROM DATE !SSLIEL' <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 Environmerltal Health Department. <br />Assessors <br />WELL Location 1930 tjue,4 freW1On+ S-Wt6 Cross Street City S�t",inn Zip 9S.)b3 Parcel# 133-300- 33 <br />PROPERTY <br />OwnerM(XN-y Came' Es{crfe Address Y(,30/ R'd4K Id ('rUr4 City 2k&k Y) Zip C.3 Phone# g8.5'-1'±S� <br />C-57 Contractor qq Address qsb i4me. i2wel City Hayhr►ez Zipgi4553 Lic# j2!U5Phone# q&S-313-5'SDU <br />_ <br />Consultant / Sub Cntr ndunmed 6mtnv,mnmejr1af Address ail Shat6 Road City Sb&&& Lic# 0bbZ 1 Phone# ao9-+01-1004 <br />01 <br />GIS Coordinates: X 'y Township Range Section <br />/1 <br />l <br />WORK TO BE PERFORMED: <br />,gNEW WELL/ BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />-1;-SOIL BORING # P -P -t -I 0 OVER -BORE. DIAMETER <br />-WELL # VAa-1 MUY�, MI& 3 0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />" <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />''MONITORING ;a HOLLOW STEM DIA. OF BOREHOLEHu t„ 0 MULTIPLE CASINGS a 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 3'arut (oo' TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE gPUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS iunt_ zla -Pbr-�land Ce rmn+ <br />0OTHER: 0 OTHER APPROX. BORING DEPTH ' uncl LPD' $'BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED ND (if YES, list specifications in comment section) <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />` <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 Ord* nce , Rule nd Regul ions, and all applicable California State Laws. <br />Signed x Title/Company V%C'_e W?50erll I (-y(3neeci (inoEnYvnn"JJ44 y-%( . <br />Print Name 'R6oeyl P. Date o + 0.0 U9 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: A 5G, W I,'J" <br />WORK PLAN DATED: OL�06W 31 2� — <br />Application Accepted By y Date Issued Area 6 <br />Grout Inspection By Date 7A 4 l 09 Final Inspection By Date CI <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />f <br />ACCOUNTING ONLY: AID# 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�3.�J IfoSO4 SROOD 5S1.6el <br />ov o� <br />C-57,ZWC-,-- -WAIVER_,_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br />EHD 29-02-001web <br />6/22/04 <br />