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U <br /> San Joaquin County f � <br /> Environmental Health Department SITE <br /> " { 304 East Weber Avenue, 3rd Floor,Stockton,CA'95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Webb: www.sjgoV.oPgft� –4 2� „ IT IV <br /> P I CE! ' <br /> Well Permit Application if s <br /> SAN ui C0UNTY <br /> NON-REFUNDABLE PERMIT EXPIRES 7 YEAR FROM DATE:ISSUEDE N <br /> I V I R 0 N H E N T A L <br /> nict I <br /> Application is hereby made to San Joaquin County for a permit to constand/or install the work describ .4414pMR rs R MTcompliance with San 1 <br /> Joaquin County Daveiopment Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> q Assessors <br /> WELL Location 1305 �.SC axe, Cross Street j o-s .rrn i� City �. Sakrj _i Zip S 3Zb ParceW <br /> PROPERTY <br /> owner_C.cic of ES a., Address P O �aA �`$ ...- City csc-ONS' Zip 'is 3Yo <br /> C-67 Contracdor\14 000w o ,d- Address_ 4 O (S%4* 3 3 C' iia °I 1Do'19 <br /> . � _ �. �ty�Zip 4S LLIc� Phoney 1+JL 300 <br /> COftu ISub Cntr�k ,\,\ ca9L�Cc1s..�JAddress wz I '1 }..S-1 _.. City �aS1� Lic*_-- Phonei#?OSS ZZ��tq J <br /> GIS Coordinates:X 'y Township Lange Section <br /> WORK TO BE-PERFQ,BMED: I� <br /> p NEIN WELL/BORINGPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ; %DESTRUCTION (choose type below) fj <br /> 0 SOIL BORING# p OVER-BORE. DIAMETER <br /> I <br /> II WELL# R PRESSURE GROUT <br /> l]•Other GROUT SPECIFICATIONS_ S <br /> I <br /> COMMENTS: e W r� 9►^� ? 11 oS C+�'lM lffnJ`F <br /> TYPE OFINS TALL&R0 E GONUCTtOtV SPECIFICATIONS <br /> 'XMONITORING la HOLLOW STEM DIA.OF BOREHOLE 1 10 a MULTIPLE CASINGS ©MULTI-LEVEL WELL CASING DIA: <br /> p EXTRACTION a AIR HAMMEWDRIVEN CASING THICKNESS-TYPE OF CASING: 0 STEEL '¢'PVC BOTHER: <br /> VALOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> AIR SPARGE!OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE' MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 'to"f✓%lf- <br /> OTHER: -0 OTHER APPROX,BORING DEPTH L't I SS�i}sy.9a 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (tf YES,list specifications In comment section) <br /> COMMENTS:- " <br /> NOTE. OFFSITE BORINGS REQUIRE /ACCESS AGREEMEN'Ti OR ENCROACHMENT PERMIT <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I I hereby certify that I have prepared this application and that the work wl11 be done in accordance with San Joaquin <br /> County Ordinances,Rules and Regulations,and all applicable California Site Laws. C.3 <br /> Signed x _ iLlrnyT_ ,�/ rEle/Company <br /> Print Name rJ G Vj00 Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS' i3oS LAW_ <br /> WORK PLAN HATED: <br /> Application Accepted By <br /> Date Issued (7 Area <br /> Grout Inspection BY lite, Date [ c v a�' Finai Inspe(:Wn By--_ <br /> _ _ <br /> Destruction Inspection By .,�,. Date n le, <br /> COMMENTS 1 CON)ITIONS: j <br /> ACCOUNTING ONLY: AD# FAC# !It <br /> PE CODES FEE INFO AMOUNT REMITTI=t7 CHECK# REC'D BY DATE I PERMIT 1 SERVICE REQUEST INVOICE <br /> SR# p0yy +05 <br /> 3. oz 6o.ec .. 3.3 r o0 oi� <br /> C-57_ WC—„-„WAIVER C-57 Letter of Authori2ation to sign permit_Encroachment doc <br /> EHD 29-02-Ml E� <br /> 5/22/04 <br /> �I <br /> 2 Jaz � I <br />