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a • San Joaquin County _ <br /> Environmental Health Department SITE <br /> ^ 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: 2M�`a'�A.4brY t4 1: 46 UNIT IV <br /> Well PermitApplicatiQi ,0A01:11H COUNTY <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FRJq ?I" I A L <br /> T1-tENT <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 /> /r f- /�/ Assessors <br /> WELL Location /'�'4 I l�WniG1l%jCross Street�`r�� 5 - City S/�aKT0,�1 Zip�SZA�o 'Parcel#JY <br /> PROPE 'r" <br /> Owner_rS{-1-�..2e_�5��'ryg ddressJ G0�0) ,vt S f�iT City_Sj cj�Zip_ff��Phone#PIC Oso <br /> C-57 Contractor Address ��-' R..rek �-o 'b Q >City� Z�ijp 4571 Lic#'�L4A?jPhone# -3G=} 34W _ 3-i <br /> Consultant/Sub Cntr UdLS Address Ztj'C Cra-Irwe„WC5 City [J Lic# Phone# olt(o <br /> #3o c7 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> AEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') �' ESTRUCTION (choose type below) <br /> n SOIL BORING# OVER-BORE. DIAMETER /D <br /> $JELL# u PRESSURE GROUT <br /> p*Other . GROUT SPECIFICATIONS <br /> COMMENTS: mom,4yrM WetI I <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> )MONITORING a HOLLOW STEM DIA.OF BOREHOLE tQj/ tWULTIPLE CASINGS p MULTI-LEVEL WELL CASING DIA: I�'Z <br /> )jjfXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: a STEEL><PVC a OTHER: <br /> 1]VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL �, TREMIE TYPE TO BE USED: Q AUGERS p HOSE <br /> `t_AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> p SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:___ 0 OTHER _ APPROX.BORING DEPTH V Ca t a64- u BOLTED TRAFFIC BOX or a STOVE PIPE <br /> c CONDUCTQR CASING PROPOSED—¢--(if YES,list specifications in comment section) <br /> COMMENTS:_ :�'�.0 G-iP)C��;D\QY� '�"' VtGtiJvt^ 4I101.J 1 <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 Ord'nan es, �� nd Re I ions,and all applicable California State Laws. 1� oAY�/iEN r <br /> Signed x ( Title/Company S '1 Ocic �EC�1�E 1� <br /> Print Name r1 Dale <br /> DEPARTMENT USE ONLY <br /> OnNIMEN <br /> SITE MAP IN UNIT IV FILE,A fTRFSS• yU I /A I, <br /> WORK PLAN DATED: z(, ' O s per, r ,t,� �� ��q 20 05 ,p H <br /> Application Accepted By I_' V\M�\nnEf _Date Issued__- °'1 1 L[a 1 0 5 _Area J Z 1 <br /> 4\ <br /> Grout Inspection By IMIAI: ._ Date ! 1 09— Final Inspection By— Date <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 /> 3s"oZ G0, o �� @, � 2.� q(a�(o� SR# ` go'6,6 <br /> C-57_ WC---WAIVER- C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 622/04 <br />