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121-Q'An Joaquin County <br /> 2 Envirbnental HealthDepartmentku <br /> SITE <br /> N A <br /> { 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd SITE <br /> F079� Well Permit Application UNIT IV <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I <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. - i! <br /> WELL Location .7 -4rort Cross Street. 74A City '1rDC�1OK/ Zi S 0 , Assessors <br /> p Parcel# /� p`2 00 i <br /> PROPER Y <br /> Owner_( r fcxVlt ( Fau Address SSI $- .q' city 1 rpurf w�. Zip 2P2 Phone# 2. <br /> 220 <br /> d kr-k.IrM <br /> C-57 Contractor En rob Addressrn v (tic d0` 3 City12rar((9- Zip9i%4 Licl-"P7 Phone# S -$t?-3O+y <br /> Consultant/Sub Cntr-6TI C C04ia&f rjj Address 2285 Ajprv)le kLjj,At City 0jUAnt ffil/Lic# Phone# �2S-bOZ-'f�/D <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: on <br /> p�'L�}�iV_ <br /> fJEW W LL/BORING (CPT,GEOPROBE, HYDROPUH, HAND-AUGER,OTHER*) p DESTRUCTION ! (choose type below) <br /> OIL BORING# HJ- thmup�_N 1.5 OCT 2 5 2OOF DOVER-BORE. DIAMETER <br /> O VWELL*Othe ) 0 PRESSURE GROUT <br /> COMMENTS: ENVIRONMENT HEALTH GROUTSPECIFICArjoNs �. <br /> FFt@iTT1'31CITdtI-i L•.'7 gi li,� ■■!__��� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS , <br /> a MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_ 0 MULTIPLE CASINGS a MULTI-LEVEL` WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 'i 0 PVC 0 OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS n HOSE <br /> 0 AIR SPARGE/OZONE JtPUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ROIL BORING 0 HAND AUGER GROUT SPECIFICATIONS k ; <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH aSr and /p BOLTED TRAFFIC BOX or 0 STOVE PIPE 1J1I` <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: 1 . Ip <br /> i <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. Y <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordina es,Ru s and Regulations, and all applicable California State Laws. f <br /> Signed x _. Title/Company L C=oqIIIID12�!jq <br /> Print Name_�Y�C�Q�,A/ /�'\�citvUc-w Date ' t(/�e�3��UQ6 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: Z,(i S-) <br /> WORK PLAN DATED: N u VS t- 2 00 C <br /> Application Accepted B -I' Dale Issued -06 Area 145-'l <br /> Grout Inspection B Date •U ` Final Inspection By '' ate (—17 • OL <br /> Destruction Inspection ByJ Date <br /> COMMENTS I CONDITIONS: 1:1 V is I b f; n- 15- <br /> ACCOUNTING <br /> SACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTEDCHECK# REC'D BY DATE PERMIT t SERVICE REQUEST#, INVOICE <br /> 350 I 89 119, U0 SR# 00 49 703 { <br /> C-57_ WC--WAIVER- C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br /> I <br />