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a <br /> San Joaquin County __ _` <br /> Environmental Health Departm Li=�( ��'�I�l� SITE <br /> 600 E. Main Street, Stockton, CA 95202-3029 MITIGATION <br /> ' (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.orkVd`,' 1 2008 UNIT IV <br /> Well Permit Application EPIVIhONPA :'l [1EA01 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISS FJIR-W,4IT/'S,RVIGFS <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 /> 21 M ,�/ C /-� ! Assessors <br /> WELL Location /, �. r/�G//�t A Cross Street C`te n h G City 7Ta n+� Zip 2-Parcel# i <br /> PROPERTY �e V6[�(A.W.t'Aefr, <br /> Owner ddress '1251VfJ P0t.dity Sr TA Zip_"hone#2.09 '? 7^Tg'V7 <br /> C-57 Contractor 60'"qrt ` Address_Z 26 Wa�A�.'TAilke. A� '�Hrl� 1075SLic# 85/65 Phone#(? S) 313-5800 <br /> Consultant/Sub Cntr T ress !Q e //•std Jr.CCT Ce�eld e �PL` tew �I✓is ry ���Lic# �^- Phone#2.0! ^osis <br /> GIS Coordinates:X 6 5 381-24,Y 2 71M.56 ,Township Range f Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/ IN CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> HSOIL BORTNG# y 0 OVER-BORE. DIAMETER <br /> 0 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 Z•'0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:------ <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE APUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> JIISOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 04,6Y_ 't.GN+.,t- <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 7 4 O Q 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: !Pj lnm� 0.mn1 1d� w:I�1 LMw►i lo— If Di A� <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 Re �ullations, and all applicable California State Laws. C <br /> Signed x fes-- Title/Company�Fso'. �.Z�O1Q�j � �en Fw,,A rG4,y� <br /> Print Name l�� �. �/�/! Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 2l <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued /C2 Area <br /> Grout Inspection By iL�r__C' Date 11 117,1®`6 Final Inspection By cam_ Date l �l <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3sor ''got.o.C9 11l� G� !a 3sf� SR# 5 S FS <br /> 35-0'i --93-1 S-1oo <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit✓ Encroachment doc_ <br /> EHD 29-02-001 web <br /> 6/22/04 <br />