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/ PO�•N -)an Joaquin County <br /> Environmental Health Department SITE <br /> r i <br /> 1 304 East Weber Avenue, 3rd Floor, Stockton CA 95202 <br /> MITIGATION <br /> + (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> UNIT IV <br /> 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 3 Z V C+C-e K e a y Cross Street c-lv f F Atte. City L o d i Zip Parcel# <br /> PROPERTY <br /> Owner J D�A v AA,1IQ � Address -151 $rwMJrj�City L 0 d Zip 9S24/oPhone# 33Y- 56110 <br /> C-57 Contractor J A. V.7 Dr, Address 100 51" S},e e4 City TS le 4v),, Zip 1 y1 Lic# 7 to0 hone# (q//0'77'1-W G� <br /> b- <br /> Consultant/Sub Cntr lr r n J h ck ZQ 1 o Address 11 l''! Mu%- Sf. City ES 11.410. Lic# S 0 t 3 Phone# S3&- I $ frb- <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> WELL# M W 1 1 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> VONITORING �R HOLLOW STEM DIA.OF BOREHOLE e" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: Z N_ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS-,,,1- 40 TYPE OF CASING: 0 STEEL '&PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Lj)1 TREMIE TYPE TO BE USED: ,&AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ijYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Ne a4- re—E.- 4- <br /> OTHER: 0 OTHER APPROX.BORING DEPTH to 5 'F4-, 20OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED N o (if YES,list specifications in comment section) <br /> COMMENTS: Or6Pie.A (-0*^ Aff-0t/ I S C' +C'Ct-0-(4. <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 ( CV-, <br /> \ rV Title/Company e-jr o, (T ea(0y S lr ro w Z t-t <br /> Print Name c)d V u Date �l Z y/�S <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: ! (ec"t{k C✓/u�Qc� y S OS <br /> V <br /> ' I op y <br /> Application Accepted B tJk,--� Date Issued O Z6'10L Area c/ <br /> Grout Inspection By Datey OS- 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 /> aq d l I ' ' 6' 6 S R#!201'3701 <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 />