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,o u t .moo San Joaquin County <br /> Envionmental Health De l SITE <br /> 304 East Weber Avenue 3rd Floor Stoc=N 2 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.g}ggv1 /�lftj� UNIT IV <br /> F° Well Permit Application <br /> ENVIRJOItNTV'EEL H <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM p$ Ij.$� ; <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location 6+ ) Ria, 1-c - Cross Street Po r�C.r R"� Assessors <br /> City c5'}c+cic�o-� Zip `15,7 parcel# 0r17-'46H-Ig <br /> PROPERTY H�"Sti T�`„� hY Tr"'Sn 4 <br /> Owner �.y��. K,u.� N P.n Address CAIS) Pfc4*� Ar— Ci �j}y�"-�„� 5 p <br /> �—C f�'1>Y _ tY Zip � 7Phone# �l —9�. ^�6 2- <br /> C-57 <br /> C-57 Contractor 671-ion Dn)It G) }„rwip <br /> —�— Address I-10�-t_c�c City l''n� Zip '�IN"1ic#Lyt� Phone#Gt -1I!>-6100 <br /> Consultant/Sub Cntrsay..�5r-�c, yTr-6pddress �l00 ffo�t'S 1S'^'wj� ,M✓tic# Phone# �'/Za 3�R' <br /> GIS Coordinates:X ,Y ,Township— N— <br /> Range_ Section <br /> `W.�O'RK TO BE PERFORMED: <br /> �p 'YEW WELL/BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER-) Q DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> WELL#�[GW--3 g Vbl�/- IOW-$-�t/bW-C� , Wdi-7 0 PRESSURE GROUT <br /> 0 Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> AMONITORING /y'F'iDLLOW STEM DIA. OF BOREHOLES 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: l� <br /> EXTRACTION NIR HAMMER/DRIVEN CASING THICKNESS HO TYPE OF CASING: 0 STEEL 'PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 11S-Z J TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br /> a AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 'Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 11i CE'W�ENT <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH �� OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOS�ED� (if YES,list specifications in comment section) <br /> COMMENTS:A�/ 41414 /' clmo,iL �o � �r�.--rn i�c_-/" (r- 6. Ce i&5 <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 R tions, and all applicable California State Laws. <br /> Signed x Title/Company_ ';W <br /> Print Name <-✓� l V Date —C> <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 1; I I Pow A FZ q l• , <br /> WORK PLAN DATED: tV 1 1 g 1 O s <br /> Application Accepted By ti`. Date Issued t O Area L/ <br /> Grout Inspection By_ LA', - . Date t t o O Final Inspection By I 10 o Date <br /> Destruction Inspection By Date .-L <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# tREC'D <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> p t/y O(, SR# X53 O b <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 />