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San Joaquin County <br /> j? �� Environmental Health Department SITE <br /> {! 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> %I (209) 468-3449 Fax: (209) 468-3433 Web : www.sjgov.org/ehd UNIT IV <br /> Well Permit Application � ! ' d <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 . Tpi,g.application is made in compliance with San <br /> Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental HHeafih epa¢tinynt„ <br /> Assessors 1 <br /> WELL Location 0$S Fi 6W0AJ S 77 Cross Street GfWAEL City Seoc*:�( icw Zip Parcel#Jy / �� 3 <br /> PROPERTY <br /> Owner SG—.eloZAO/A /1I0Address 119j ESA. ilyTg ✓A/City S?OcKTon/ Zip 9��ySa�� o 7Phone# 9.�72 <br /> C-57 Contractor Wood yjct✓cl bA (�ru4ddress P170d ( 33 �j City o 1 Zip %7S7(ic# 7/007T'hone# _7n 57q 430 0 <br /> Consultant / Sub Cntr PrTG /}SIOc /A&reS Address // / 7l.OnlEPSAIAVE City MODEST$ Lic# Phone# S'79 .1aa/ <br /> GIS Coordinates: X., Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') 0 DESTRUCTION (choose type below) <br /> D0 ILBO ING # DOVER-BORE. DIAMETER <br /> ELL # Al E[ LS M l 3 + M a//S �' M i 0 PRESSURE GROUT <br /> 0 `Other // GROUT SPECIFICATIONS <br /> COMMENTS: c• ffE 4.* oA0:?LAN DA • 61b /o / oS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> B'li/ <br /> 0NITORING 2<01-LOW STEM DIA. OF BOREHOLE / 0 r ' flIOULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 2 U <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SCN N C TYPE OF CASING: 0 STEEL eVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ✓ 4X/ 49L C TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT) GROUT SEAL PUMPED: ees g No (NOTE : MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS ! <br /> 0 OTHER:.0 OTHER APPROX. BORING DEPTH z90 ' 4- / NO ' 9<01TTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED YCS (if YES, list specifications in comment section) <br /> COMMENTS: l '/.0.[ $ ' SrW 3/0 PUG i o / 20 ' FoR Mrd is <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 is application and that the work will be done in accordance with San Joaquin <br /> County Ordinance^s, RA�es an a latians, and all applicable California State Laws. <br /> Signed x �a— " / Title/Company PLofESS/oaAL /' E� oy ,y / S_ _� <br /> Print Name i oD � �A' � Date 6 <br /> DEPARTM"E" NT USE <br /> ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : 2.0 d-S /tyr �a+ ✓l <br /> WORK PLAN DATEDc :�/1 / A OS <br /> Application Accepted By /, ` ' Date Issued (O ' ��� Area <br /> Grout Inspection By LAS • .,, •. e- - Date 9 i }�Ob 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 /> :60j � 9 � 3(,$ b �tGzyc SR# 'f7 � 5 <br /> 01 <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 />