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��Urry San Joaquin County <br /> SITE <br /> r ^ ! <br /> Environmental Health Departmen 1, <br /> }.. �:< <br /> 3Q4 East Weber Avenue,3rd!Floor, Stockton, CA 95202 MITIGATION <br /> 1 <br /> t,'.y®. °' : 'a j (209)468-3449.Fax: {209)4(.8-3433 Web: Www.sjgov.org/eBTC 9 2004 UNIT IV <br /> Well Permit Application E � 01ibF;,j'';: <br /> it.iiIfl <br /> - r��, �.- �.,r.X11'�• .4' <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSI-16HE 1NI �'-j�[ 3VICES <br /> S <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 /> Assessors <br /> IL <br /> WELL Location 1 e5 V G t-4ni1;n C l>l�Cross Street Tl�. k_ __City Trac -zip_q k Parcel# <br /> PROPERTY a�rpO TpSIe ZbC Cil CaC Zip 53 (.Phone# %3 -{x599 <br /> Owner JT Sidra P_ Address, Y <br /> n 3�3z Gr-,e�'C' y � p S74ZLi�71_)SIO Phone#`!A(.' 63$-WA <br /> C-57Contractor (_ASLQ,drrt Address �7 1r'LIe CII Or era Zi <br /> Consultant ISub Cntr �L Address�31 SAno.L...I 10690.227 Phone# L67-100(o <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL!BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) .'DESTRUCTION (choose type below) <br /> D SOIL BORIt4G# gOVER-BORE. DIAMETER g <br /> %WELL# tnhl 1 n PRESSURE GROUT <br /> 0.Other GROUT SPECIFICATIONS 4I9L411 b Sc�cIC <br /> COMMENT& 0 rbr.m. fia �mLLk�A\ 't\, C Mer, FPr 5��e t,Je 115 _ <br /> TYPE CF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> IONS <br /> )PAONITORING 0 HOLLOW STEM DIA.OI"BOREH.0LE_49_ 0 MULT IDLE C^.SINGS U IMULTI-LEVEL WELL CASING DlA: a <br /> 0 EXTRACTION 0 AIR HAMMERlDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL lU PVC IZ OTHER: <br /> []VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE T'PE TO BE JSED: p AUGERS B HGSE <br /> 0 AIR SPARGE]OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 3 No (&9O E: MAXIMUM FREE-FALL DEPTH IS 34') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: rj <br /> OTHER APPROX.SORWG DE?T i AS N BOLTED TRr^F i0 BOX or [l STOVE PIPL <br /> t 4 ` CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS:GinLCOG Gr�Mtn� Frame C.>,1 G 'rt'q G <br /> 'T1'L��u vvt t �-a C�ro�.c - C-ttic lvr� 11 tw do yf-e r <br /> P-10 'E: OI==SI i E EORINGS REQUIRE ACCtSS AGREEAP.FNI.T R <br /> 43 WORKING HOURS NOi REQUIRED FOR INSPECTIONS. <br /> I hereby cart' t I have epare this application and that the work will be done in accordance with San Joaquin <br /> County Or I and ions d all applicable California State Laws. q <br /> Signed x TitlelCompany p. - r A GE <br /> t_1 <br /> Print Nam.6,,:S. Date <br /> ,DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS:_..,2Y?, U <br /> WORK PLAN DATED: C1i3i e <br /> Application Accepted By Date Issued Z 6010 y Area Z <br /> Grout Inspection By I LI6n c,, Date 2 Final Inspection By _ T Date I2 S� <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'O BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> 214`13 V1 ro a y S R# 0 6 3 <br /> C-57 WC--WAIVERR C-57 Letter of Authorization to sign permit_Encroachment doc� <br /> E> D 29-02-001 <br /> 6/22104 <br />