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6 1 °`"" San Joaquin County o , Envik. mental Health Department i` 11 I i ''/r l I Jl SITE j 600 E.Main Street, Stockton, CA 95202-3029 MITIGATION (209)4 68-3449 Fax: (209)468-3433 Web: www,sjgov.org/ehd�.)�l., _I ] UNIT IV Well Permit Application NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDTOE - 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 Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. l.r r FpFina 7t S7' (' Assessors - WELL Location FCC) Q r ; rReuolG.'}�-- �fi Cross street L,33 0 57, city c�/CC:f,'Ti,,;J Zip �5: 1 parcel# !'433 046 PROPERTY f Owner i�'.hf-.J , anhii i I"'"d"'J Address �Pf(;.(, F iQrtn- � S7, cny.S /Gi.i.Ft••'1-Zip C-57 Contractor AAddress S-- -1 SA'1LA% '0'_j = FCAy�li;c l!ry�Zip �/> Lic#�5cs?Z 1Phonei 16 Consultant/Sub Cntr ,C,: Address 9>'3.7 Si%A ✓ r4 y iC r,. �-'� (Z�0- y�7.-/oo G Git S I ci. t•:-�Lic#�. z�7 Phoneme# GIS Coordinates:X ,Y _ ,Township Range��S WORK TO BE PERFORMED: jjj�/// NEW WELL/ BORING (CPT, EOPROB !HYDROPUNCH,HAND-AUGER,OTHER•) D DESTRUCTION (choose type below) `$SOIL BORING# 0-r'3 -v DOVER-BORE. DIAMETER 0 WELL# 0 PRESSURE GROUT - � a*Other �^ GROUT SPECIFICATIONS r1t COMMENTS: .��' f1 C',: Sian .C1a - ) l.,Fi-> i �� ' J� •..�-iry,. �/- ^1 A�'tfiC t'i4n% c6l JQ �1 Zo"=7 i TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS D MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE- " 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: D EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS N!A I TYPE OF CASING: 0 STEEL D PVC 0 OTHER: A)j.A -0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL S7/ _ TREMIE TYPE TO BE USED: D AUGERS .HOSE j 0 AIR SPARGE/OZONE AkPUSH POINT GP or CPT)GROUT SEAL PUMPED:.0 Yespp,U'No .(NOTE: MAXIMUM FREE-FALL DEPTH IS 30') SOIL BORING 0 HAND AUGER ..GROUT SPECIFICATIONS rC�2Tlra.'ui'� D OTHER:_0 OTHER APPROX.BORING DEPTH S ' BOLTED TRAFFIC BOX or D STOVE PIPE - CONDUCTOR CASING PROPOSED tv%,9 YES, list specifications pecifications/./in°^commI enZt section) COMMENTS: c<- .e, yT / 1 P 25 f '^ EAll 27 / NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations, and all applicable California S ate Laws. .. r Signed x �M1.:-*(�:r,�"�i /� /a , Vi.^p�"N.'�-{ � ! Title/Company_ C1�t'i-.I `�C/�C7_�%r S�1 f Print Name v S,/ /;.;,q Ti4 _! �1 : C Oi.�/.r�-ham' Date_ '!�7f Iry f DEPARTMENT USE•ONLY t / - SITE MAP IN UNIT IV FILE,ADDRESS: 4 10 0 F . 'FrerY-�n m a I S 1 Y P 1 S-6 - o n WORK PLAN DATED: J V U 9 �On rJ and 1-e)7 rU Or ( ; �2R nnrl Application Accepted By V in}nr i n M /'�Ytn e v Date Issued 9 /2109 Area /,/ S Grout Inspection By J�C�+DY me r Date /5�-07 Final Inspection By V'L m Date S �/7- 0] Destruction Inspection By _ Date COMMENTS I CONDITIONS: ` K7�''- tz d P- 50. 1 d S I I lOn;. ACCOUNTING ONLY: AID# FAC# - - PE CODES FEE INFO AMOUNT REMITTED CHECK# . RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE oa 2(0o20 e z o7 sR# 0051496 C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ EHD 29-02-001web 6/22/04 - - i