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' 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: www.sjgov.org/ehd UNIT IV <br /> `'F Well Permit Application 2005 OCT 19 AM 10- 31 <br /> PON-RAFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATA&AW, 1 i') C Q U N T Y <br /> ImUNr�t F TALY <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work d"ngdT. rj �Rp i�rl f e in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental ea h d rtrtie <br /> Assessors <br /> Location L0 UN CkAk(_ Vk%ross Street VAACity �CC`1w Zip 1ff-W& Parcel# 6S L/0-0-7 <br /> PROPER <br /> Owner 5-114 011 l'rClfS CA d ess ZcJF i 1`S� (t/� N Cky t?t�y Zip!� ts�0 Phone# <br /> C-57 Contractor Y�� cAddress qJ -a t(14c i- l� City 11144 Z/ipa/W7Lic# $�Y�hone# 3/3S1fQ0 <br /> Consultant/SubCntr �� <Ml- Address J����/�`S .S✓tf City �v4 a/L Lic# f0)Z-V'7-Phone# ���� �/2U'333-j <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERF ED: <br /> NEW WELL/ SCPT,GEOPROBE,HYQQR,OPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> ^ $OIL BORING# Pr-(-i I Gtr-t h Q OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0`Other GROUT SPECIFICATIONS <br /> COMMENTS: 0,_3 Skin 'Z,-t4 - g-� et ­�� A,L11-1 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOL °-' 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/a q0 Q.SvTREMIE TYPE TO BE USED: JfAUGERS E HOSE S <br /> 0 AIR SPARGE/OZONE`�USH POINT(GP CP GROUT SEAL PUMPED: Yes QNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> .SOIL BORING /0__HAND AUGER GROUT SPECIFICATIONS A101A F�1+ ur t [I <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH B`� �' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> c_- r CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: G PT- yv,i c yr-i`-L c &-^ STj I e,,, . GPT-- 16 61 Ar, G/Q" <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 Ordinan s, Rules and Regulatio ,and all applicable CaliforniaStateLaws. (' Sc <br /> /' <br /> Signed Title/Company QPMr Y� c� "�� -S` AC.�6f-*N- <br /> Pri �-e L Date � V <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 620 e1?,gr+-ey- Wa v <br /> WORK PLAN DATED: A da ,)C -1- 31 20 0 <br /> Application Accepted By i Z. d-- Date Issued -OS' Area ! SJ <br /> Grout Inspection By i /}7 Date S Final Inspection By ` 1'IZ ate Ld -2J-DS <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: A4j v e n A p,n.,a vi Le G P5—14 C P r- 14 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR# j04411 7 <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 />