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'Jan Joaquin County <br /> Environmental Health Department SITE <br /> `304-East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (309, 18-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNORMIAIT IV <br /> AR I <br /> . <br /> 9`'F0R Well Permit Application <br /> NVIRQNh�rPv i <br /> PFr p 1!T+CC! (M*WFUNDABLE 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 Health Department. <br /> l /� / / Assessors d <br /> WELL Location 3 SJ ��H !�✓l/' Cross Street 10a f%�05-1 City STov� � Zip �1�D Parcel# /? 0 Z_ <br /> PROPERTY // v 3 �!s��„� Y q'� Phone# G 114 'S241 -/// 3 <br /> Owner �1�, � C Lt�l Address � Cit S'>�� Zip <br /> C-57 Contractoroly"!//`1� Address /!).90 u 334 CityrQln t/,cfk Zip 9y571 Lic#-74007't Phone#707 -394_cE3 o v <br /> G <br /> Consultant/Sub Cntr ,eg,kl �a fie �4 Address /S��i/(90/dv�,s 5�G City ia.-/D tk Lic# Phone#Zoe► GGA- Gg�y <br /> GIS Coordinates:X Y Township Range Section �1 <br /> WORK TO BE PERFORMED: <br /> ANEW WELL/BORING (CPT,G OPROBE, HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> ,SOIL BORING# SB- 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT v1 <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING VOLLOW STEM DIA.OF BOREHOLE— 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS -VI TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL O — /00 TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: `g Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> !SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 0 BOL ED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED e-/l4 (if YES,list specifications in comment section) <br /> COMMENTS: <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. <br /> Signed x / Title/Company /'�Osf v 6t!/ii'071 <br /> C4�Z I;r-C- <br /> Print Name �✓G✓�'� /` ��'�/ti Date <br /> DEPARTMENT USEONLY I/�� <br /> SITE MAP IN UNIT IV FILE,ADDRESS: _-3 !7S-S- M ti n 4 rf td V em r,e <br /> WORK PLAN DATED: J4 n trd r N Z!9, -2607 <br /> Application Accepted B Date Issued Area 14.59 <br /> Grout Inspection By Date g Final Inspection By 1 " ate <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: 12 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE ST# INVOICE <br /> 3so3 sa 37+ 00 R# <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroac oc__ <br /> EHD 29-02-001 <br /> 6/22/04 <br />