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I <br />an Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />SITE <br />MITIGATION <br />UNIT IV <br />Well Permit Application 1005 MAY 18- <br />PM 1: <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 de fl4b fl 'Th s jj*1(6a)Oh^jS'Irr�de in compliance with San <br />County rUrt� tai 441tl bb, q iLnent. <br />FEE INFO AMOUNT REMITTED <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin �ny+ <br />q tY P p 1- LLL I" hl <br />REC'D BY <br />`+ DE to : rk j 1UTAssessors, <br />Street 01°'UAYCity S���tJ Zip I Z°Parcel# <br />16o3 S0 -E' STKif-f x-- <br />INVOICE <br />WELL Location Cross <br />PROPERTY 11 STOCK f�nJ iSZo� Zo�1 q14 -787 <br />CAL 13 S <br />16� 3 SO. Q STif-riT City Zip Phone#,In <br />Owner -l"13 _Address <br />4st1 � wi.'.lr4ti Address ?0 Sox S118Z City PA AU) Zip q4 3Lic#604g97Phone#G6SO 3Z2 -28s1 <br />C-57 Contractor <br />5 Ec,0ti- !"In- Address S% WAIYE-VC- 01L CitY WA'y ic# NA- Phone# <br />Consultant/ Sub Cntr <br />GIS Coordinates: X Y , Township Range Section <br />WORK TO BE PERFORMED: <br />�OVEW WELL/ BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />_ <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />WELL# VELI -IVC-0-L . �S '� ?i�(�ukFF aSt.J"µ 0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />0 *Other <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS // 0 <br />8')1" MULTI-LEVEL WELL CASING DIA: '� 6 <br />\j <br />0 MONITORING '15HOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 <br />';EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SC++ 40 TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br />$ AUGERS HOSE <br />;RVAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL �8-I- TREMIE TYPE TO BE USED: 0 <br />DEPTH IS In, <br />FAIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL ) <br />0 SOIL BORING 0HAND AUGER GROUT SPECIFICATIONS 7 S-%, aE.�vNr (�(( 7'0 <br />! �"-'�� <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH 30 `l-9 3I BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED r (if YES, list specifications in comment section) <br />COMMENTS: <br />i <br />KWITG- nGPciTF RORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTION5. <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 � l <br />��/%c—� (-"Ae-� Title/Company tL_ (N (Z (NGO(LpoaA <br />Print Name <br />A4,L., 4 S7 -E L t J A -r-), Date S- ( % - o f <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: cl I ' <br />/ l r" Area l , i <br />' " <br />Application Accepted By Date Issued � �-i � �.✓%'� <br />Grout Inspection By Date Final Inspection By gs O Date_l/ <br />L.. <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />nr�r�i inirini r_ nnn v�Irli! Gore <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PE RVICE REQUEST # <br />INVOICE <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 />