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San Joaquin County ri n'�,�MAI <br />Environmental Health Department <br />!": { 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br />209 468-3449 Fax: 209 468-3433 Web: www.sjgov.org/ehd ( > ( � �g � UNIT IV <br />Well Permit Application r <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I ? l 1 ( J <br />!b 9�d <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 complia an <br />Joaquin <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. / `77 UUu 0 <br />4 <br />Z 8o W c t Lame. A l r ne, AVC.. `fSZON Assessors <br />WELL Location 1 5 Cross Street P cityS��KfO N Zip Parcel# <br />PROPERTY MI II Grrej�- 1313 w. r--6bjnhooc0 SfoGKfon y5407 <br />Owner Lq Z,;tre. L L L Address Srni& A • I t City Zip Phone# <br />C-57 Contractor /I*tG/S1 Oki Address Q E55Cx die.. Ityich n+on� i, Itq ic# 363 one#Siad 3%' q%.s <br />10( WtiilC oclL/2v1. /2a bO <br />Consultant/ Sub Cntr 6uma4mc Address Su He- / 00 City CCr #VA Lic# N A P h o e#G1l6, 63(6 ZdQ <br />GIS Coordinates: <br />Township Ra <br />Section <br />WORK TO BE PERFORMED: <br />p NEW WELL / BORING ( EOPROBE. HYDROPUNCH, HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br />0 SOIL BORING # b rih S m loa ra 0 OVER -BORE. DIAMETER <br />0 WELL # 0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS Nea_4 c eztpnd fo ° 3' <br />COMMENT& fad r;qV wi l f 0-c cLd tfaac4 4r- Soi 1, SoilyWc,. ' aftJ �q /'a 4-ndwa4f- Su,"p e 1��loci S <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE Z 'r 0 MULTIPLE CASINGS 0 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 SEAL7!jO� g,5 TREMIE TYPE TO BE USED: 0 AUGERS <HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED<0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br />OTHE Dit't�f •�u511pPPROX. BORING DEPTH* 5 ,..brleL-j 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />0 OTHER: 6 <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: 4 50; f Vooy-r' CJ U � <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. —y <br />Signed x // \ Title/Company-k <br />Print Name <br />�(/ /�`ecl�LS� Date <br />SITE MAP IN UNIT IV <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By_ <br />41, b ( V1 Final Inspection By <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />AreaDate c fl <br />ACCOUN ING ONLY: AID# FAC# <br />PE ZODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT / SERVICE INVOICE <br />7.01,5 01, <br />m.00 <br />$Ot.0L? <br />It 1-nk <br />Al'�, <br />1-Vt-(,dk SR# oo5 DOW, <br />C-57 ✓/ WAIVER— C-57 Letter of Authorization to sign permit ✓ Encroachment doc <br />EHD 29-02-001 <br />6/22/04 <br />