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'..n Joaquin County�C�I���^ <br />Environmental Health Department L�IJ SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MAR 12 CGGMITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />ENV, UNIT IV <br />'RONAODI�i HEALTH <br />Well Permit Application PERMIT/SERVIUES <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 Health Department. <br />11.. tI Assessors <br />WELL Location ZZ''I�l �Sp A� Ut W Cross Street ,��= Cy� City e bV1 Zip �{ 2C(p Parcel# �bQ-0g0 -s5 <br />tri LT Ar yt <br />PROPER <br />Owner Ar/f,�'Pctb(,�-n•Mu-J11lV-+4�6Ol�V U1�CANdiUdYrKeGsys �p/dd4rpes1s r �0�l' Lry[O-VW�ySi city i�11//0 2 <br />hone <br />C-57 Contractor 411" -Lk A6vi6wayti-Address 3�O eSQ) It `Cilop-L1UZip 9r1ic#f� q4 2957Pho9ne�# 1g -am D 9) 0t31i— <br />13y� <br />�1n)L '� DCity Y�c# PhoneConsultant <br />GIS Coordinates: X Y Township Range (D Section ZZ <br />WORK TO BE PERFORMED: <br />`KNEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />'WELL # Mhl TyW - - W-5 0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING HOLLOW STEM DIA. OF BOREHOLE M 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 2- <br />1( <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS66V1tC4 4'V TYPE OF CASING: 0 STEEL XPVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL -1 TREMIE TYPE TO BE USED: XAUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 11e-ctQ C-P-KM.eu-C <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH {�� BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />p CONDUCTOR CASING PROPOSED IJ O (if YES, list specifications in comment section) <br />COMMENTS:- 5(�C- Ct+ p GOP��it �u cC�t�4gY7��v�y <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 Or finances, R les and Regulations, and all applicable California State Laws. <br />Signed x Title/Company �v^n' , Co(.O t'i,,�ttom� <br />i tit ItJ L <br />Print Name Date �'No- <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: e,,,r� <br />WORK PLAN DATED: 5 11 o'E LW�w-�1� Z tz of V w - y W -h <br />Application Accepted By num`' wJ-t- Date Issued Area 6 L l <br />Grout Inspection By Date Final Inspection By Date Z -� <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY. <br />AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE <br />PE E REQUEST # INVOICE <br />— <br />3ivl <br />.�J <br />3 � 3- 0J <br />l S'k�� <br />3 .�,,, <br />S R# v v , 34.& l <br />155-7. <br />a- q. ,,,, <br />C -57-A[ WC�-WAIVER_ C-57 Letter of Authorization to sign permits Encroachment doc <br />EHD 29-02-001 <br />6/22/04 <br />