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0 0 2�2�p� tan Joaquin County .9 fCOPY <br /> IS <br /> s IS Vronmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 MITIGATION <br /> (104948-3449 Fax: (209)468-3433 Web:www.sjgov.org/ehd UNIT IV <br /> VIRONMENT HEALTH Well Permit Application ^ � <br /> PERMIT/SERVICES <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 6 <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 <br /> San Joaquin County Environmental Health Department. <br /> �/Z S�Al �L6Q rL Cross Street JfNrV L) Ci (cal RON Zi Assessors <br /> WELL Location _ ty p `15366 Parcel# 4010 <br /> PROPERTYA, p 1 ON'I!p <br /> Owner �VF,rtEG �4 Addrese6/1C�R.l�. Citys��T'p, 54-31.one# <br /> C-57 Contractor Q666 l>r;II-'-h9T,-A', Address `TO Powe Rd: i zqCy A_4jiNEt Zip 45 Lic#l&q Phone# qZS-.7i3-SROu - <br /> Consultant/Sub Cntr h,0.MAb-x t Af1)4A"kr Address 2iol WPa1rE2 Pt, IH-r City dAKEAvD Lic# Phone# 310-663-1/La0 <br /> GIS Coordinates:X r 74 831 aom y L/5/&z00 , ,Township Range Section <br /> WORK TO BE PERFORMED: LAT.' 34;yy lyA1 Lore: /zl:o7-,' 19W <br /> ,KNEW WELL/BORING CPT,GEOPROBE, YDROPUNC HAND-AUGER,OTHER•) p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0.Other GROUT SPECIFICATIONS <br /> COMMENTS: 5- J t0 CPT bar' V + IZo feet bre Sof IO bly�r w cl — �FVr 5106W JNduttix/ Ave <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> p MONITORING p HOLLOW STEM DIA.OF BOREHOLE_ p MULTIPLE CASINGS p MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE PUSH POINT(GP onp-PT-)GROUT SEAL PUMPED: 0 Yes� 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ,'SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS_ t�(nrl:'r��y'e A,cf N�f'-Cen,h.F trbot <br /> OTHER: fl OTHER APPROX.BORING DEPTH 1Z0 ✓eet 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED ('d YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> —x 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 \ > �7 Title/Company�rMta+' c�,�v..cr <br /> Print Name Date 8' 1 0! <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 2307 5• UJDU.5r2.(.A"L P+Po,,, — GUR_U&_Cf5 <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued Z 7`0 5 Area Q <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 I SERVICE REQUEST# INVOICE <br /> 2911 I sl 0W2 1.7•(3 SR# 3� z Z <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc r4 <br /> EHD 29-02-001 <br />