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San Joaquin County G <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 <br /> MITIGATION <br /> _ w (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> 9 �Fa2005 OCT 19 AM 10 36 <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSbl!dl' J 0 A l3!"I C U U N T Y <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work descrit"8.Lfl T I i N, 1 E T A ompliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmen al�F{{ea th ep rtfrl lnt.'G�I <br /> O (j G�f,� V- Assessors <br /> cation Cross Street City c. N Zip g�02 Parcel# <br /> PROPER }}_� S-CC I �_\� ,. 1 /( �( I - q '/ <br /> Owner Ej_'j O S�kAVMAddress 62y W�� l-F-W(4t(- City-:SsCX�1� zip Phone# 2Ujjq) 13�_<6_ 36 <br /> C-57 Contractor , Addressy-c �((2GQ 1City �r`R�Zzip� Lic# fG�yf�hone# 2S 313 SS�oo <br /> Consultant/Sub Cntr +� �ddress <br /> GIS Coordinates:X 'Y Township Range Section <br /> W RK TO BE PERF MED: <br /> EW WELL/4PRI (C�,GEOPROBE,HYDRO U CH,HAND-AUGER,OTHER-) Q DESTRUCTION (choose type below) <br /> Q SOIL BO I -# ('PT-11; 1 Q OVER-BORE. DIAMETER <br /> Q WELL# / Q PRESSURE GROUT <br /> Q*Other1 - GROUT SPECIFICATIONS <br /> _ <br /> COMMENTS: ,1-N A_)c Vock L '^ 601 *q9 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING Q HOLLOW STEM DIA.OF BOREHOLE+Zr Q MULTIPLE CASINGS <br /> Q MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL Q PVC Q OTHER: <br /> Q VAPOR �0 MUD ROTARY DEPTH OF GROUT SEAL�o 1 Q H�REMIE TYPE TO BE USED: UGERS QF <br /> Q AIR SPARGE/OZONE �f.PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes Q No (NOTE: MAXIMUM' FREE-FALL DEPTH IS 301) <br /> jkOIL BORING Q HAND AUGER GROUT SPECIFICATIONS• c)�G<k Nem- GQVvNn.r` <br /> Q OTHER: Q OTHER APPROX.BORING DEPTH 3 4et0O yl il?qO' BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CoNDU TOR CASING PROPOSED YES,list specifications in comment section) <br /> COMMENTS: C O + -g0_ /op I i <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 Regation and all a=licable California State Laws. ) �� <br /> Signed x Title/Company " +0(, <br /> Date 1 C2 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS (0 2 O \N e-s+ Ckjr+&r Wo V <br /> WORK PLAN DATED: Au A U S t 31, zo D 5 <br /> Application Accepted By Date Issued 16 - 19-65- Area 14 5 9 <br /> Grout Inspection By I` Date / 2 V1dj_Final Inspection By V i r t Y-&h'fd#jyxK Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: Pr- -)'7 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3501 �9 �4 /G i o SR# 0 014±4 5- <br /> C-57 <br /> C-57WC -WAIVER. C-57 Letter of Authorization to sign <br /> i permit_Encroachment dooc_ <br /> 6/22/04 02-001 CP <br /> Ti - 18 <br /> n D- �V O c-.-G�dC/' � Y 14e b S L�+ �l t✓L'<y�7�1[ C� S e,&v_v <br /> CPT - k-1- 1443 Pa.l o�' r-°-e'` +z 4'�, , rh.a /� fa r�ej <br />