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,o San Joaquin County ✓iq �'�'( % <br /> Environmental Health Deparle"t a 4 - SITE <br /> 600 E.Main Street, Stockton, CA 95202- 09 �� MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.or1­/chd UNIT IV <br /> ° Well Permit Application <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&/1115.3 and the Standards of San Joaquin County�Ennvironmental Health Department. <br /> WELL Location l lr60' 1—• I-O0 i5e. kfe. Cross Street McK��City 4LL�Zip 3=90 Parrcel#Assessors <br /> 1 y0—r� <br /> COMI'TfGI'tLl <br /> PROPERTY Bt7llddi�flcc�� /�_ p p <br /> OwnerLA1nngi/1trtY5iCilr-p Address Po B/9Y Ib0 1 C;ty Zip9 i�honep�?D9 98-�J')9(0 <br /> C-57 ContractorWnC,i,el2 ibC tia Address q. 0 a"n I?A 98$city ;pgSG,HSL;c 133N hone# - `ag29 <br /> Consultant/Sub Cntr EA t t T�chr C_Address Bks P 4k%dR�L;c# PhonefFT� 3�R 9o0 <br /> 4 p1 p I <br /> GIS Coordinates:XG)R3DY,Y I ZI i[O &' ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# Id 0 OVER-BORE. DIAMETER <br /> g WELL# 0 PRESSURE GROUT <br /> 0.Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_ 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 BOTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE I PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> e SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH C 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (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 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi lances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x n n Title/Company t5 <br /> Print Name �w t 1, Date J <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IVFILE, ADDRESS: 000QtfV0se AOC 4 jl,5`6 <br /> WORK PLAN DATED: <br /> Application Accepted By Dale Issued -] 11�/Q7 Area J'7 J <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR#no <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> ERD 29-02-001 web <br /> 6/22/04 <br />