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.- FILE COPY <br /> a �a San Joaquin County <br /> cZ Environmental Health Department... v`. ,�1 �IEnl I PITE <br /> m < 304 East Weber Avenue, 3rd Floor,Stockton,CA MITIGATION <br /> • (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/ehd UNIT IV <br /> L/FoRN`P• Well Permit Application 04 OCT 2 I /PM1 66 p� . <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (�✓W"`� �-- <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 9-1 and the tandards of San Joaquin County Environmental Health Department. <br /> _ C ()jlty ,..F�, Assessors <br /> WELL Location I l 1) ^n rossss Street l'I^,�J�I'��••'T' Ci l �c kt" Zip 1521 P'n,.W q� -i ^ 43` <br /> OwnerPROP <br /> S,� ,`n t� Address (Mo ALp^t n" "C oC l Zip j;4 Phone# p0 — 7�{l ^ROT <br /> C-57 Contractor <br /> W04'2-fm yUy,,v,/� Add{re�sns YOVo')C 6p5�L Cdy��$b"_`RZ.iip,,Q�;61�Liri1 S X(%one#q_5116��L'l k'�d <br /> Consultant/Sub Cntr AoIGt' FDW;C1'WAddress (001 Clr%t "JCiN�APU"� Phone# (Ib –M <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERF RMED: <br /> NEW WELL/ RIN (CPT, EOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION (choose type below) <br /> ®CSOIL BORING# OVER-BORE. DIAMETER <br /> a WELL# RPRESSURE GROUT <br /> 0.Other GROUT SPECIFICATIONS <br /> COMMENTS: nl�(ow 5f)2M, L 9 - <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �^r <br /> 0 MONITORING HOLLOW STEM DIA.OF BOREHOLE $�� 0 MULTIPLE CASINGS �MULTI-LEVEL WELL CASING DIA::A///^gyp <br /> EI EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE QF CASING: O STEEL 11 PVC Q OTHER: <br /> u VAPOR 13 MUD ROTARY DEPTH OF GROUT SEAL 6 ^ b° f EMIE TYPE TO BE USED: .AUGERS a HOSE <br /> p AIR SPARGE)OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: $(Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ''SOIL BORING a HAND AUGER .GROUT SPECIFICATIONS g4a4'(b1 i& <br /> 0 OTHER: O OTHER APPROX.BORING DEPTH SD-- 10't9"a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED ILIO (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 7M1w P-n `II�"'� Title/Company <br /> Print Name �kS(in Y <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued �l Area <br /> Grout Inspection By Date Final Inspection B ate <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FELE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUESTS INVOICE <br /> X <br /> D 13 — /33 SR# <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment do, <br /> EHD 29-02-001 <br /> 6/22/04 <br />