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`"Uo Uy:57 FAX 9166792900 <br />t,RS -SACRAMENTO-GO <br />F-riv!rn,rhmental Health Depart,oent <br />304 East Weber A� enue, 3rd Fleof, Stockton, "`A 95202 <br />(209) 4`)8-3.149 Fax: (209) 468-34- 3 Web: www.,;gov.org/ehd <br />Well Permit Application <br />Z002/004 <br />SITE <br />MITIGATION <br />UNIT IV <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 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 <br />Health Department. <br />WELL Location ws3TsrD¢-oFc�l�e15M4.v <br />RD,_ Cross Street Scr/ Qp, City -rZ4 <br />c.ZrZ- Assessors <br />PROPERTY 257—ZiP Parcel# <br />O� na" v✓ccr�yi �w Address <br />Zip -r sz s2P <br />City Phone# <br />C�57 Contractor %LCS2o G �oSU 140�C' <br />-� Address /�O¢9 F-RSr IL ggnJ SAVE. SA A <br />City f�SPRaa"s Zip � 7DLic# <br />Consultant /Sub Cntr�/Q$ GD Phone# 562- 5103 - <br />Address oar <br />T—�Qo+GATION _261-i0ew!!r �rejp�zDR- <br />�rbs_ iCity��,y„q i —=_Phone# 916-679 2ae0 <br />GIS Coordinates: XPI�� (0;0141 � `'`` <br />Y Z-08'774 Township �'ZS �• _ <br />At -(0301853 otaRange_{ZS(T <br />WORK TO BE PERFORMED: t ----___ Section <br />EW WELL/ BORINGPi = 5e bN 2-7 <br />G OPP,OBE, HYGROFUNCH, HAND -AUGER, OTHER•) 0 DESTRUCTION (choose type below) <br />`,SOIL BORING # S I Ptd <br />0 WELL # <br />U *Other 0 OVER -BORE. DIAMETER <br />0 PRESSURE GROUT <br />COMMENTS: ORO 'T SPECIFICATIONS <br />TYPE OF WELL-, <br />INSTALLATI <br />0 MONITORING ON TYPE CONSTRUCTION SPECIFICATIONS <br />0 HOLLOW STEM DIA, OF BOREHOLE h.25 " <br />0 EXTRACTION 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: -- <br />0AIR HAMMER/DRIVEN CASING THICKNESS <br />0 VAPOR 0 MUD ROTARYDEPTH 0 STEEL 0 PVC BOTHER, <br />_ <br />OF GROUT SEAL 30_t (0" TREMIE TYPE TO BE USED: GAUGERS <br />0 AIR SPARGE) OZONE ,PUSH POINT (GP or CPj] HOSE <br />T)GROUT SEAL PUMPED: <br />0 SOIL BORING 0 HAND AUGER 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 OTHER: GROUT SPECIFICATIONS T - p 5 '-bo. <br />-�0 OTHER <br />APPROX. BORING DEPTH_ 30" <br />0 BOLTED TRAFFIC 90X or 0 STOVE PIPE <br />COMMENTS: Z C.�PT :PUS CONDUCTOR CASING PROPOSED <br />�f f U,JS rL SHt� L.OU -- (if YES, list specifications in comment section) <br />D 94-S. <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCI?ner�u■x=.1T .,...__ <br />�o "uMMING HOURS NOTICE REQUIRED FOR INSPECTIONS. r;Rmt r,, <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 <br />Print Name Title/Company Ur2S c yLpp qT/on/ <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, Ar�DREuS: <br />WORK PLAN DATED: UE4 -51�2 <br />Application Accepted By <br />Grout Inspection By c1--�'�t� /,# Date Issued 4 t o 4=- <br />Date -*t�f, f Fina! Inspection By Area <br />Destruction Inspection By Date <br />- � Date <br />_._. <br />COMMENTS / CONDmrNc• l(/n <br />I ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES FEE INFO AMOUNT REMr: ,.d SC„E,,,., M � <br />2�C'D 01 DATE PERMIT/SERVICE REc2UEST # <br />INVOICE <br />o <br />= WAIVER l DYE 00 q 3 7 rl 3 <br />C-57— WC <br />C-57 Letter of Authorization to sign permit__ _ Encroachmen <br />rHD zy-oz-oai <br />6/22/04 — <br />