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ILr �1 V San Joaquin County <br /> L C ><y�Dnmental Health Department SITE <br /> j 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 /> 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 Count Development Title,Chapter&1115.3 and the Stan ards of San Joaquin County Environmental Health Department. <br /> q y n� p ���e pAVo IQa¢onµ , 90v 6/n(Asseaaomo4 LtNOS/FYa/MINE, <br /> WELL Location(iL� #�Sto(:kl0rt -0 .Cross reef City JLip ParceNf <br /> PROPE T.1' l�� w r s 02 Phone# 2 937-8399 <br /> Owner 'I'T.) O� Sac-lc�� Adtlress,�"tgSr,Nr C��( � City .� Zipp��� <br /> C-57 Contractor�t�g�.A1� Address 1Ov [�O(a7f- IKG n� City ��1"��2�Zip rrLic# i Phone# /.3 5800 <br /> Consultant/Sub Cntf*W#7"d IS/tl. Address837 Straw 9 City uV Uc# X12 Phone#_e * 7-/DO(i <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERF D: <br /> EW WELL B.QRIN (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) p DESTRUCTION (choose type below) <br /> a SOIL BORING# a OVER-BORE. DIAMETER <br /> WELL# O PRESSURE GROUT <br /> r0th r GROAT SPECIFICATIONS <br /> COMMENT s�A ('PT -mAd y�Leorinti Zoea7tY0/XS _ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING O HOLLOW STEM DIA.OF BOREHOLE-2_// a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:_Al <br /> p EXTRACTION u AIR HAMMER/DRIVEN CASING THICKNESS N1A TYPE OF CASING: O STEEL 0 PVC p OTHER: <br /> 0 VAPOR p MUD ROTARY DEPTH OF GROUT SEAL f V7.tQ TREMIE TYPE TO BE USED: Q AUGERS a HOSE <br /> p AIR SPARGE/OZONE XPUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONSrf/ewn..�au r„ 4- <br /> XOTHER: C Pf p 'Lb OTHER APPROX.BORING DEPTH '1-2 5'T c�-f a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED A)�/-I- (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. /1 n <br /> Signedx� Title/Company � �Ia�I S�"�F1-O�VrW<.ILcge�cGL(J <br /> Print Name k A rt (-2k V-0-, IM6e- `� Date )2 16101 <br /> DEPARTMENT USE ONLY 1 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 109 N t r� rrra ri+ aS+r e e " <br /> WORK PLAN DATED: oc}o be r .20 - 2004 <br /> Application Accepted By_ } _Date Issued b 9 2 007A ea- /471 <br /> Grout Inspection By Date I2-14-0 k Final Inspect S <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: T C <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3501 89.00 a1, 89. 00 SR4 0()40423 <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 622/04 <br />