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n Joaquin County <br />//off� /a <br />Enviro ental Health Departs Ql ccsSITE <br />600 E. Main Street, Stockton, CA 95202-3029 // F/Ev MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjg4EcRghd v UNIT IV <br />jFo W Well Permit ApplicationE�VIR0A1 <br />, �rdr���=I <br />uo? 0 IN i ON <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATpr,qA E <br />E ti��IJ$ tvr/G, 4Lr� <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This a'�iplication 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 />1 // Assessors <br />WELL Location �'-/( E. %1a; n 5 i-, ee Cross Street 2-".t.5" r City Zip 15364 Parcel# 2 6 / 0 -0'7 <br />PROPERTY( G <br />Owner 8a( o i d -Ll kc,e Anje_ Address�sy3SS I J4�+H4;— City l�rtei f Z- p 9yn6 Phone# i9 <br />C-57 Contractor �G511f�►t/1cu. ri%'' dd s3195 Lt♦•,�,.� �:.re City Llp9S7YLLic#87` %#Phone# 114'�.�%:StS[�/ <br />Consultant/ Sub Cntr4)�MAL-/Ce.ne,,&♦#40*a`�adsess{4YK7Rre✓i.:urCitySOA,,.WLic# Phone#i07-Q33-2j47 <br />GIS Coordinates: X 'Y Township Range Section <br />WORK TO BE PERFORMED: <br />a NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />0 SOIL BORING # <br />0 WELL # <br />0 'Other <br />is A -1w -1,n L1 -Z <br />DESTRUCTION (choose type below) v s <br />a OVER -BORE. DIAMETER <br />PRESSURE GROUT <br />GROUT SPECIFICATIONS POALY=/ cC�•-c. �� <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 41 � <br />M0ONITORING a HOLLOW STEM DIA. OF BOREHOLEr1 Qua MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS c.4 JfQ TYPE OF CASING: a STEEL )KPVC a OTHER: <br />a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALt,,A'01X ATREMIE TYPE TO BE USED: a AUGERS ,R'HOSE <br />a AIR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: &Yes a No (NOTE: MAXIMU� FREE -FALL DEPTH IS 30') <br />0 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS p_ `y1Zr e_c^a_ - <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH a BOLTED TRAFFIC BOX or a STOVE PIPE <br />4 CONDUCTOR CASING PROPOSED IyA (if YES, list specifications in comment section) <br />COMMENTS: r l i v r <br />t.�� �► .3 wail �.. (� fr P/eS,S�.�s� <br />NOTE: OFFSIT� BORINGS REQUIRE ACCtSS AGREEMENT O� 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 />Countyd�inannces,, RVl/e'7s anil Regulations, and all applicable California State Laws. <br />Signed x // C,�-= V� Title/Company <br />Print Name C <br />DEPARTMENT USE ONLY <br />_Date Issued L0 S' D ? Area <br />Final Inspection ByyWACarfw+.,Date <br />- -� „ -. <br />ACCOUNTING ONLY: <br />AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE ST # <br />INVOICE <br />3502G0, <br />00 <br />ZD. ©D <br />�co45- <br />t'w <br />/-0 SR# OOS2I 94- � <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit --Encroachment doe <br />EHD 29-02-00 l web <br />6/22/04 <br />