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U <br /> P 'N Qan Joaquin County �>�c <br /> o • .. .,� <br /> Environmental Health Department SITE <br /> ���. rl'✓;,� <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95702 ` "5 ^ MITIGATION <br /> • (209)468-3449 Fax: (209)468-3433 Web: www.sigov org"d IGoS UNIT IV <br /> Q�100 Well Permit Application ;`;e7Y��` < <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ication is <br /> Application <br /> Joaquin hereby <br /> Deve Development Title,toaquin ChapteC9-11 5.3ounty randthelt to construct Standards f San/or Jo quint the work described. This County Environmental Health IDepartmentade in compliance with San <br /> q y Assessors ���^O 1� <br /> WELL Location <br /> S+ot.k•I-k41PAlt-1 ARD Cross Street EAST § 5-f;City SToLkToN Zip 9520(o Parcel# <br /> PROPERTY LAN'" ?Af k F►L (,Vll Phone# 401-171-5600 <br /> Owner RAIL.R.,wo CuM4ANy Address IN16 (�o�GES'�QEET City oMp►iQ,1�E Zip <br /> SORo Zip <br /> � <br /> 677Lic# Z�'hone# 510- 51.8-716-71 <br /> C-57 Contractor VZRoNEX Address a►10 ADAMS PVE CityAA RIO <br /> Consultant/Sub Cntr KENNE0y 'SE11k5 Address l-31so G0L'0 EN"6SL City t--QoiYA Lic# Phone# quo $58-27a� <br /> oz., 5tt. 350 <br /> GIS Coordinates:X <br /> 3 �. 3 Y - (2(.Z (12 ,Township 1N Range L E Section a-a <br /> WORK TO BE PERFORMED: DESTRUCTION (choose type below) <br /> JINEW WELL/ BORING (CPT,GEOP OBE, HYDROPUNCH,HAND AUGER,OTHER*) �0 OVER BORE. DIAMETER <br /> SOIL BORING# /5 S F3 — S /� ) B PRESSURE GROUT <br /> 0 WELL# GROUT SPECIFICATIONS <br /> 0*Other <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING B HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS B MULTI-LEVEL WELL CASING DIA`.______ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: B STEEL B PVC BOTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: B AUGERS B HOSE <br /> 0 AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes B No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS cl <br /> 0 OTHER: BOTHER APPROX.BORING DEPTH o �'(- B BOLTED TRAFFIC BOX or B STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <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 Ordina ules Regulations, and all applicable California State Laws. ^ <br /> Signed x <br /> Title/Company u;a2 t"t -5 7- <br /> Signed <br /> {7✓NC --�c l <br /> Date /d <br /> Print Name '� <br /> DEPAR MENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By <br /> Date Issued /d Area `l g <br /> Grout Inspection By <br /> Date D Final Inspection By Date <br /> Destruction Inspection By Dat <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# #FAC#PE CODES FEE INFO AMOUNT REMITTED CHECK# DATEPERMIT/SERVICE REQUEST# INVOICE <br /> �q U I QZZz/ Z-'1 /e, o� SR# 0 2�v<- <br /> C-57_ WC—WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> fit-ID 29-02-001 <br /> 0/22/04 <br />