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UI <br /> pIY <br /> Jan Joaquin County <br /> Environmental Health Department SITE <br /> ' <br /> i 304 East �Aeber Avenue, 3rd Floor, Stockton CA 95202� MITIGATION <br /> (209) 468-34.19 Fax: (209)468-3433 Web: www.sjgov.org/elid <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 /> WELL Location 0130y"C+tJ� Ra." Cross Street G l Assessors <br /> d F(• City Lodi Zip Parcel# O y q-O S-2 3 <br /> PROPERTY <br /> Owner NdrCrvvv, AddressN;LZ. Pebble_ RQAckCity S�-ock{•a-, Zip Phone# 9y8- gylz <br /> C-57 Contractor V 4 W Vc:Ili^6 Address 100 5{t C{ee C+- City zipMvqj Lic# 7Z070YPhone# (9'1(o)777 00 <br /> Consultant/Sub Cntr U'r0v✓+cl zco"D Address 1714 Ma,- L+. City BSc .,Lic# Sot ? Phone# 838'" Yegg' <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> y,NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> SOIL BORING* I 0 OVER-BORE, DIAMETER <br /> WELL# 0 PRESSURE GROUT <br /> ),`Other_Da� wEll S Mwt, '"I' <br /> w 3' M W 4, MWS S iU W(o GROUT SPECIFICATIONS <br /> COMMENTS: e.xl�;jArin,) We0i W;11 be cye/d":Iled and rf- 1r-%f--Med w:11+ a d_e2Ae/ (,tee*_4c4 �'��e'✓�� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 1! HOLLOW STEM DIA.OF BOREHOLE 8" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 7-11 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS Sck.• 40 TYPE OF CASING: 0 STEEL APVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 4 1 1 TREMIE TYPE TO BE USED: RAUGERS 0 HOSE <br /> AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS ,V#-c-.+ Ce V.P_n4- <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH l0 5 F.L. .81,1301-TED TRAFFIC BOX or 0 STOVEPIPE <br /> CONDUCTOR CASING PROPOSED N d (if YES,list specifications in comment section) <br /> COMMENTS: ted c—%A---c.4-irnn I eA-\+C' [,%eat <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 U Title/Company 5'FC-0* �/'e o l 0 y�S)�, (l rd�✓�ra 'Ze r o <br /> Print Name J o e- \j v`e Date <br /> T <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: b, CC&--'4 A .¢tet VA Dr <br /> Application Accepted B Date Issued Area �'Q7 <br /> Grout Inspection Byi�� Date 1 P 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 /> ply?y3 W/- �� OS SR#DU�37vv <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EMD 29-02-001 <br /> 6/22/04 <br />