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"' San Joaquin County <br /> z � Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> �d �% <br /> OV 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 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Z 6 /V, � G ha A A� 520Z- <br /> Assessors <br /> q Z50-26 <br /> WELL Location i c(n c� Cross Street City JrT21c ¢e Zip Parcel#_ 3 J <br /> PROPERTY Q Rej-vt I cr r,,i.I 7-�Q PT- I <br /> Owner L t4 c'1 S701�1-n 11 Address q25 /V• E) Do('do City S�C'�1�tN� ZipgJ�ZC2Phone# �J� —7.5'17 <br /> C-57 Contractor Ft S L S OC I L!1 c, Address 3qq 5H i(i> PIA C G _City Valli 5 r�2S 952-.67 Lic# - 3aES Phone,6D9772-'357,0 <br /> Consultant/Sub Cntrco � ' -SC�y <br /> Lic# Phone# <br /> GIS Coordinates:X Y Township_ Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/ ORING) (CPT, EOPROBE, YDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> SOIL B G# 95 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 Zih 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 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 X, <br /> USH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS YleA T-cc <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH Q 7- 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS:_ �jl�� l i.1��L. 4,-f inn t1,L�f� 7 .P <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 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 RecWlations, and all applicable California State Laws. <br /> Co,,L+ / <br /> Signed x Title/Company c� aT I�' pec k n o f tlaf CS In c <br /> Print Name / L_O 0 Date V1 710 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: Z14 ry • C^ C- S4 <br /> WORK PLAN DATED: .J.o� I 2 c�cs g <br /> Application Accepted By (�4�M--Ce _Date Issued t zD <br /> 9 / ,s{ Area <br /> Grout Inspection By U Date Z l �(7 Final Inspection By Date z tfi j.Q� <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 /> 35 o t gs ss .oG SR# <br /> 3so3 i od O�SSI51 G>F I ���t(o� 532,5ZZ <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 />