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r� } <br /> San Joaquin County SEP ^ <br /> z Environmental Health Depart ent ® .!007 SITE <br /> k # 600 E. Main Street, Stockton,CA 95202Of��9Eli f� MITIGATION <br /> (209)468-3449 Fax:(209)468-3433 Web:www.sjgRVI�rS t(� 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 O yU f 2 <br /> WELL Location _7ro-"]S l.� I(E�1 St Cross Street Ckr�i s nn&„(W City�Af_q Zip Parcel# <br /> PROPERTY 1 1 <br /> Owner `eVov1vx2 I'll 1\ +� Address Po 130>c 3r� CityI Zip C llPhone# 2011 835-3%(;0 <br /> C-57 Contractor Address ZZO N.1✓as{ St ip 'L Lic# Phone# S30-(0(05-2-4?--{ <br /> Consultant/Sub Cntr ATC Nssoc . Address I l 7 Lowe.Pal inn City sToLic# Phone#?eR 579-Z1 <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ,ANEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> SOIL BORING# (04tetjV ob¢T G�C� a OVER-BORE. DIAMETER <br /> a WELL# 0 PRESSURE GROUT <br /> Q*Other qGROUT SPECIFICATIONS <br /> COMMENTS: Ia �f'�10���.V1 ��t� �J�u l, Z00-7 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC a OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL l�t TREMIE TYPE TO BE USED: O AUGERS a HOSE <br /> a AIR SPARGE/OZONE ,`PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ,SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER: Il OTHER APPROX.BORING DEPTH I S l Q BOLTED TRAFFIC BOX or a 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 Ordinances, Rules and Regulations,and all applicable California State Laws. /► <br /> Signed x , I Title/Company -Br'o-n1,/��Y Ar- (C- f-t S50G <br /> Print Name Date / 0 7 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 7-175 W <br /> WORK PLAN DATED: 09 &kt( lav 7 <br /> Application Accepted By L1* 4Date Issued / 7 Area <br /> Grout Inspection By Date 'd 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 /> 354,3 7 9( ' 3&3 °v I1fv53 CPT,Z- 9 10 O/ SR# oa5t899 <br /> C-57 Llweb <br /> =WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02 <br /> 6/22/04 Ct/� 2*a / <br /> ``''j �(�(.t, <br /> 5�� tW(sIR(Cr 5 <br />