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San Joaquin County <br /> yEnvii% ,mental 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 /> c� <br /> Z05 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 i%,rrmo' ��,o' fiche th San <br /> Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health �r11;t Q�� p � 11 <br /> WELL Location 5Li E 6a-V S-i Cross Street.N,0414xia ,7T City 9wkhA, Zip Parcel# /39-1(5--09 <br /> PROPERTY <br /> ICS p <br /> Owner C fiAddress IZ8 ��lUirP 6 City �elixV IIS ZipY�5Zk Phone# <br /> C-57 Contractor AdV& W4 Genf Wiftl(W `fAddress 93.7 5�6LW t2.4 City�_Zip 545'Lic#&SVI 7 Phone# �7/DVb <br /> Consultant/Sub Cntr_AdZkW eCICf VifBgg"W Address 37 ,ALA City5W4rt Lic# 6'gOZZ,7 Phone# 07-1104; <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ANEW WELL/ BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br /> J SOIL BORING# ' 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 0 MULTIPLE CASINGS <br /> 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 _4t4A-j TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes >(No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> )ErSOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Pvr` A4tvted- <br /> 0 OTHER:_o OTHER APPROX. BORING DEPTH 00 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 I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. '� � ^@ <br /> Signed x ��i�{L(} �t rr`' 1 Title/Company l�pj /�► QUC�IR C'�CLt�l�i'rDAll<f � <br /> Print Name YQy1� L� �15V� f <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: k-4, -,-A,y"'k C;1, C:{-N-lr 1-� <br /> WORK PLAN DATED: -4-c 2-'6 , -z00 5 <br /> Application Accepted By--UL" '--C .-- Date Issued_ Area <br /> Grout Inspection By Date Final Inspection By Date I p <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY. AID# F <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ?.S', V-1,C K- <br /> 3 '` 5 t; z -1`1,— Z -- tl( SR# <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 />