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San Joaquin County <br /> Envi► -amental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> ,�. <br /> � R 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 /> N r1 (�S f E' - Assessors <br /> WELL Location Cross Street- l'ee eet 1 h e.5 T, City ��/ Zip Parcel# <br /> PROPERTYv1 4vP <br /> L. 47-04L <br /> Owner /4 L 47-0 4 L Address W�S��t1ll City d�l Zip ho e# 20q-_�U`1--'yz(z leo. <br /> C-57 Contractor_6aynGCX4-1SlenSNti t <br /> Address1ff6 �,_,wq-da AVE city F n4-anazipq�`33L.ic#5100//Phone# <br /> y_ zg3. <br /> 1 p <br /> Consultant/Sub Cntr_L�C ge'lCd(06!0 �/1 <br /> /1 Address 1,3!52 /Ue&k-5Q1ud City�oSPU( Cic# Phone# <br /> GIS Coordinates:X ' Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# q 0 PRESSURE GROUT <br /> 0*Other. l K s P4 L)t4 t l O cr) W� GROUT SPECIFIONS <br /> COMMENTS: lr Spa nye , Z itr 5'1)a,- Pe -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �1 <br /> MONITORING "-4-OLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 5-4,qy TYPE OF CASING: a STEEL )PVC 0 OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 730 TREMIE TYPE TO BE USED: 0 AUGERS )�,}iOSE <br /> 'XAIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 4eq tc e 1,en 71 S 770 �e <br /> 0 OTHER:_0 OTHER APPROX. BORING DEPTH S-0-70 '�&LTED TRAFFIC BOX or 0 STOVE PIPE <br /> J /C0ND TOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: 56 M e U Q 11 / Q r�O�I2 Z.////J" C'Pf 6? <br /> a <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 od Regulations, and all applicable California State Laws. <br /> Signed x / \ nTitle/Company <br /> rn <br /> Print Name (� a `/ 9 4 a(f_eA' Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: CJ„¢_� usy <br /> WORK PLAN DATED: CLjZtj12C)3 jjam_ <br /> Application Accepted/B1 1��n pn-t/� r�� Date Issued-&Z/ L6 S­ Area <br /> Grout Inspection B Date 2 J b 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 /> a �o� 8� - 8� � ���� L' R SR# <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 />