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San J(oaguin; unJ _ <br /> 1y ! J <br /> Environmental Health Department <br /> j� r "'� •j! 304 East Weber Avenue, 3rd Floor, Stockton CA`9�2btI + I'-ri-,'�, SITE <br /> 209 / `. MITIGATION <br /> n j ( )468-3449 Fax: (209)468-343 We : www.sjgov.org/ehd <br /> b <br /> Well Permit Application 04 DEC 16 PM 8. 47 UNIT IV <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 County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location_ 029.5 N. HdAre.4k Cross Street: S r-, City S'1-o�}C}o... 7_i .50212_ Assessors <br /> p J Parcel# <br /> PROPS Y p -- <br /> Owner_ n q Cc 1Znnin aeon Address 9135 N. µ,I�rt�l. City S�-oc.k�-oh zip 9satz Phone# 931' qO 9_Z <br /> C-57 Contractor ErVv;r00rd6e Address_3SI T—OrN- y(7-/00(0 <br /> �—if�r City Brea Zip I Lim��°��Phone,.f_ <br /> Consultant/SubCntrA V0L')CeA Coep Address 91� S4\aw City SIocKFpnLic# �W ) phone# y�7 1006 <br /> GIs Coordinates:X Y Township Range_. Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> SOIL BORING# S�-I — SQ- I I p OVER-BORE. DIAMETER <br /> a WELL# <br /> p PRESSURE GROUT <br /> Q'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> O MONITCRING 0 HOLLOW STEM DIA.OF BOREHOLE 1,12.5 a MULTIPLE CASINGS D MULTI-LEVEL V'JELL CAS;NG DIA:______ <br /> 0 E(TRACTICN 0 AIR NAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL O PVC OCT.—ER' <br /> 0 VAPCR p MUD ROTARYO DEPTH CF GROUT SEAL_ToT+`t Oe.o}�. TREMIE TYPE TO BE USED: p AUGERS [I HOSE <br /> 0 AIR SPARGE/OZONE 'PUSH POINT P rCPT)GRCUT SEAL PUMPED: 0 Yes -RNc (NOTE: MAXIMUM FRET=-FALL DEPTH I9 301, <br /> p SOIL BORING 0 HAND AUGE. GROUT SPECIFICATIONS <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH '3Fi' �>SG a BOLTED TRAFFIC BOX or G STOVE PIPE <br /> CONDUCTCR CASING PROPOSED­N 0 (if YES,list specifications in comment section.) <br /> COMMENTS: <br /> NOTE: OH:SITE EOR]MGS REQUIRE ADC ESS AGR'EEtVIEN—, OR ENCROACHMENT PERM!T S. <br /> ^� 43 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certifvlthat I have reparad this application and that the work will be done in accordance with San Joaquin <br /> County O i nces ul -Regulations,and all applicable California <br /> n�State Laws. nn AA <br /> Signed x _ Title/Company �( <br /> _�'i�e^4- F"Or Ahyo nceJ Geo <br /> PrintNam G�riS'�U17�Cr M�,�Gr Date <br /> DEPARTMENT USE PNLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: OZ6S /1/• /� 7�� �` — �� <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued ��� Area/. <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# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR# 00 Z8 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc N <br /> EHD 29-02-001 <br /> 6/22/04 <br />