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�An Joaquin County <br /> MIR nvironmental Health Department SITE <br /> ® zql304 East Weber Avenue,3rd Floor,Stockton,CA 95202 MITIGATION <br /> ;468-3449 Fax: (209)468-3433 Web:www.sigov.org/ehd UNIT IV <br /> HIMENT HEALTI•t <br /> PERMIT/SERVICES 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,(lChhapt/er 9-1116.3 and the Standards of San <br /> Joaquin County Environmental Heafth Department. <br /> WELL Locati,T'u MAV"!"1 A Gross Street .5 City. k' k,A ZipParcelAssessors � <br /> Q Parcel <br /> PROPER (, A <br /> Owner b k f� Address a�__�t 4/t4ef Ave City 56k." ZiP 5W Phonei <br /> C-57 Contractor ' CthruflQ rl����' OmAddresflvaa DL,CICiAc. City ZiP�157q 115i6 Phone#-l''�'��. <br /> ContiultantlSubC r r4Fr1/11U�idN ��Address /��iv", 2w1r�ilN(tJi err Yisn!°11�A�4 ����Z 7. <br /> T <br /> 1._.r...,....�� dy q4- Luh Phone#5J'3°-(7l� C1J Z <br /> GIS Coordinates:X Y Township Range Section <br /> w R PERFORMED, <br /> EW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,NAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> 8 SOIL BORIN # 0 OVER-BORE. DIAMETER <br /> rLL* W-I Il tn/TJ�2�Ai j� 0 PRESSURE GROUT <br /> her , GROUT SPECIFICATIONS <br /> COMMENTS: 19 SuvL,i , 7bext Z'`FVG C <br /> TY12E QF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> )(MONITORING OLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: Z,� <br /> 0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS ,k4O TYPE OF CASING: a STEEL `PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL t TREMIE TYPE TO BE USED: Q AUGERS HOSE <br /> AIR SPARGE!OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED` Yes 1a No (N. O1TE: MAXIMUM FREE-FALL DEPTH 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS /ltd <br /> ©OTHER:- fl OTHER APPROX.BORING DEPTH S'' 'BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED nA (if YES,list specifications in comment section) <br /> COMMENTS: V <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. 1 <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that'/ have Prepared this application and that the work will be dome in accordance with San Joaquin <br /> County O 1nga�nces,Rules and Regulations,and all applicable'CaliforniaLaws. <br /> Signed x LCA �(!L'C H`;�� Tib] /Company 5Sta5w;t.,nl2 i y{� CCC�v�a �s <br /> Print Name J � li''��f _ Date 1�d� 1 <br /> DEPARTMENT USE.ONLY <br /> SITE MAP IN UNIT IV FILE ADDRESS: 0S C✓L�-C ' S Tbr-tea.. -�� 5i� "'^�'cs' 1.. f � <br /> WORK PLAN DATED: !�D <br /> Application Accepted By Date Issued N y 1 0-7 Area q 7 <br /> Grout Inspection By ^_Date.( D Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: " I 1. ! <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE " PERMIT/SERVICE REQUEST# INVOICE <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 />