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D <br /> ' o San Joaquin County � <br /> Environmental Health Department SITE <br /> ' 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www,sjgov.org/ehd 'flP UNIT IV <br /> +14t" <br /> ' �F-° Well Permit Application 3 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED wtuie OrQVIN� <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 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Me.r^fs.n Assessors <br /> WELL Location/98SS /�/. 6I-AAf Grte QdCross Street Hoose PKW)rCily T_ zip 9539/ Parcel#_,X09-6/ap-A31 <br /> PROPER <br /> Owner / ue/ai E/14.f Address53Ap7 Ravin Flower D✓.aty Y mo Zip? SO Phone# <br /> P p <br /> C-67 ConhactoAW Dri(�in�,tnC /Address 0. 8OX �/6 City _Zip IIV�Lic#720?OVPhoneA(?/6)777-5//00 <br /> ' Consultant/Sub CntrWQ1(4Ct-�k'Kq/!TSJ46, ddress ?q10 w.ff"40/, *fjtfA06k�w Licu Phone#(201)2_71f-772.2 <br /> GIS Coordinates:X '�� Y ,Township g J Range__Y&_Section 14) <br /> WORK TO BE PERFORMED: <br /> ' ?'NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') D DESTRUCTION (choose type below) <br /> 0 SOIL BORING# D OVER-BORE. DIAMETER <br /> �'VJELL#M14 D z , -D 3,M -081f 0 PRESSURE GROUT <br /> 0.Other GROUT SPECIFICATIONS <br /> ' COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ' )f MONITORING `HOLLOW STEM DIA.OF BOREHOLE rr D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: .2 It <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSSGSL NO TYPE OF CASING: D STEEL rVC D OTHER: <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ) AUGERS 8 HOSE <br /> D AIR SPARGE/OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED:Wes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30 ) <br /> D SOIL BORING O HAND AUGER GROUT SPECIFICATIONSyte#tt ceMe.tt <br /> O OTHER: O OTHER APPROX.BORING DEPTH_25' a BOLTED TRAFFIC BOX or`'STOVE PIPE <br /> CONDUCTOR CASING PROPOSED—^/O (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 xTitle/Company/r0� Caco%/sf 1tAWt/aee-kuh/ eAs-uc, <br /> Print Name Fred W. G;44-s Date r A 4Agg5� Z^� y ZOOS <br /> ' DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: l0 `7�8d /7 c�G6-Its l�bf • /f/ cs-P �9 6s <br /> WORK PLAN DATED: ffl-24-Of <br /> ' Application Accepted By Date Issued ��� / Area GG <br /> Grout Inspection By Date 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#'/ RECD BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> ' /ilk DOG7 X2(0 SR# DO7�lS�SCa <br /> C-57_ WC ✓WAIVER_ C-57 Letter of Authorization to sign permit ✓EncpecAment doc_ . �, 01, <br /> EHD 29-02-001h <br /> 6/22/04 C <br /> l� <br />