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`,l.n Joaquin County <br /> EnviroLihental 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 /> �P <br /> 'Fay 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 /> Assessors <br /> WELL Location �1 E C�L(�. 1�)Eh 6. Cross StreetS��Ai�`L(�,V1 City�Q- Zip Assessors <br /> PROPERTY 11 <br /> OWner5Waya" OAntAk#N, a Address a . U&p �(��{-,`V City Zi 'hone# <br /> C-57 Contractorlesl Ay4,Li(,oL �n�� h Address"o .` �1(� &U?City_.&,V �nGIi.,Zip CL2Q.0(Lic#8 t`lS Phone#7 04-'13q- �' <br /> Ac�V t4nLt <br /> Consultant/Sub Cntr ��F ice. tW��vw _Address 'D37 .Iii..) _City - I ic#(o 2g ZZ Phone# l-}b:7 - ( 00(¢ <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 /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> $WELL# T&\r2e, - I✓ wPl s 2 Gw&:� Wd[� - 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING -Q:�10LLOW STEM DIA. OF BOREHOLE " 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SL\A . 4D TYPE OF CASING: 0 STEEL .(PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ^-' V TREMIE TYPE TO BE USED: ACAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS C$ho,Zd <br /> 0 OTHER:_o OTHER APPROX. BORING DEPTH ;S�BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASINGZrA <br /> POSED NO (if YES, list specifications in comment section) <br /> ,z <br /> COMMENTS: A N20 ,�p��1 d c��Q-lr'k IIP � (� (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 Or Inanc Rules and Regulations, and all applicable California State Laws. 1 <br /> Signed x Title/Company 1 1A LaL,(p -)�,,✓,w- <br /> OROA I . V✓�PI�"�'C <br /> Print Name �,�l' y ue f_ Date i'1/J �� 1� l ;c <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: //// <br /> Application Accepted By /YC HEAJdE/<-SC)/V Date Issued U!/ v SOd 4/ Area <br /> Grout Inspection By Date Final Inspection By TTT Date <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 /> o/ <br /> 3 3 >lig.9 g`3Gb °4 23 �5/ Civrie SR# 00'f '729 1 <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 />