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OPgD�Noan Joaquin County RLE <br /> Y <br /> Environmental Health Department p <br /> y. L�C�C�Ii MITIGATION <br /> a z ?<, 600 E.Main Street, Stockton,CA 95202-3029 UNIT IV <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> APR 7 21388 <br /> QI,FORs Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED-1NUl(}aNh!El;i I Il N lcompliance with San <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. TC1is-a � h@f+L�?r'��t7��ri <br /> Assessors; <br /> Joaquin County Development Title.Chapter 9-1115,.,3 and the Standards San Joaquin County +;b nmenial Healthpep2 V ZParcel# (�t - <br /> ViA$ate 11l>✓:!x-06 g�-✓'e^'fCr�St7-�f �L. C(,,,1-/D� ``17 <br /> WELL Location �i q� � �,(��JI �7'�.phone#61'V_ 83311 <br /> POROe ER7;. c1_ Vi 5 I• let, UUrO�[.c;�+3 City�Zip <br /> (. J,� + Addres �d4o Zip157t '7175IDPhone#�I(D 3�B Ilw-1 <br /> r�{ Addres �32 Ci � �iI JJ,,'' �7 <br /> C-57 Contracto S./ phone#"'!V I i�— <br /> Addres lHn tL"J pyL L� CitYJJs�c�"-Lic# <br /> Consultant/Sub Cntr ��� Section <br /> Township Range <br /> GIS Coordinates:X 'Y-�—I <br /> WORK TO BE PERFORMED: DESTRUCTION (choose type below) <br /> EW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 00 OVER-BORE. DIAMETER <br /> 0 SOIL BORING# 0 PRESSURE GROUT <br /> XWELL# GROUT SPECIFICATIONS <br /> -n-C r / <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONSIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:2 L19r�i( <br /> MONITORING )'HOLLOW STEM DIA.OF BOREHOLE aTYPE A CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 EXTRACTION O AIR HAMMERIDRIVEN CASING THICKNESS HOSE <br /> 0 VAPOR O MUD ROTARY DEPTH OF GROUT SEALZS to ILcry EME TYPE TO BE USED Z/AUGERS TE! MAXIMUM FREE-` B <br /> FALL DEPTH IS 301 <br /> 0 AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: X91 0 No <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS b' ��� BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH I ,tr <br /> M I` CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <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 Regulations, and all applicable California State Laws.. / <br /> Signed xw ""'"� �t"V- TitlelCompany6-tpii1�- 0/fit �T <br /> Print Name <br /> e l l h� �i� -Date T <br /> DEPARTMENT USE ONLY 1 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 3 bR 00y+)j. Ongrl 4- S+re e]- OP <br /> WORK PLAN DATED: ebr r� 2 20 <br /> �� r+n✓ A L. hAp �r �^ Date Issued .4 -0,2 _____,Area l4Sq <br /> Application Accepted By <br /> Y1. vla-1 /tle./Jj]r+'sr- Date Jr-(-t� D Final Inspection By Viefi r' L J�1aCCr iY'I"M1 Date 5 `2-D <br /> Grout Inspection By - - - �— <br /> Destruction Inspection By V Date <br /> COMMENTS/CONDITIONS: 1.ri I Sf. <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> 3s o3 � �00 383, 00 1 21/30? 4;f 41 -D8 SRO UOS SI <br /> C-57— WC=WAIVER_ C-57 Letter of Authorization to sign permit—Encroachment doc— <br /> EHD 29-02-001web <br /> 6/22/04 <br />