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D n Joaquin County <br /> r <br /> Envirfflftental Health Depa "It,f RA/7 SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA-95202-` <br /> wwMITIGATION <br /> (209) 468-3449 Fax: (209) 468-3433 Web: w .sjgAw.prtekdL 06 UNIT IV <br /> ° Well Permit ApplicationFLjVhL,,a,G ,pJ7 IiEhL?h <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DARgiMUbr-,9�/I C, <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_37 S LSI. f�g ZEi}� f�,,.�. Cross Street S. 1­inceln � CitY Assessors <br /> +o� ZiP20 <br /> Parcel#_ 1K�1�.008 <br /> PROPERTY //`` O <br /> Owner Sierrn "6,r y�a+�da4� (s Address Pn. uox ( 2)(, City C+e�Zip `5-Zc . Phone# (209�9a3-'17?? <br /> \ <br /> C-57 Contractor_ ascade Address 3(,32 )✓aee �'r CityCn�ov Zip 1514Z Lick'I '15lo phone#_(41&�(e38-Il(q <br /> Consultant/Sub CntrAa Cv t V;r. —I Address 937 Straw )2,� . City S ,, L_k.. Lic# (20-2—Z-f Phone# (Zeg1 yia�- IpoG <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO PERFORMED: �r ^ <br /> f`(l'1�J[,'�°"',�, <br /> p NEW WEE LL/ BORING (CPT,GEOPROBE,HPDR PER*) T61ESTRUCTION (choose type below) <br /> 0 SOIL BORING# p OVER-BORE. DIAMETER <br /> WELL# � a-PRESSURE GROUT ��� 1 Orsr{J� <br /> O'Other LM S�lY ^( 20�� GROUTGROUT SPECIFICATIONS T <br /> COMMENTS: pp��RR pp����TT//��� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRtJe7 NWaEIONS <br /> ErMONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_aL 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 2` <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS - . q0 TYPE OF CASING: 0 STEEL 0-f5VC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 1i ` TREMIE TYPE TO BE USED: 0 AUGERS KHOSE <br /> n AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: )(Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> n SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONSjj�� Dz l�>-� [.ow,� <br /> n OTHER: 0 OTHER APPROX.BORING DEPTH 21(� BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br /> COMMENTS: `'r IDes}r,. .,¢)I ,M W-I J —40P Ca4e--= <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 X „---_1_ Title/Company S+�-f Imt.l e <br /> Print Ndlne q �M �` L, .n M�.v� Date y- 2-6G <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: 61f,4 /o! ZoQ(n <br /> p ,5 i <br /> Application Accepted By ` Date Issuedy/�o/06 'M <br /> Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By f�y[�{ Date y l) <br /> COMMENTS I CONDITIONS:/M&I) <br /> ACCOUNTING ONLY: AID# F <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC-D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3 •02 6o.c� (oo.00 SR# Y <br /> So 50 .00 -Z381 l�t� yi80� (X5 9 <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />