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�"° San Joaquin CountV <br /> of <br /> Envidomental Health De artm�*L,, J SITE <br /> `�. 304 East Weber Avenue 3rd Floor Stockton, CA 95202 <br /> (209) 468-3449 Fax: (209)468-3433 Web: �.sjgov.or hjh 2005 MITIGATION <br /> P J'ENC 0��pjti UNIT IV <br /> '4t► o��'� Well Permit Application r��111Rr <br /> ERM��tI00 VERi <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FRDM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install t e work described. This application is made in compliance with San <br /> Joaquin County Development Title, Chapter 9-1115.3 and the Standards of qan Joaquin ou ty Environmental Health Department. <br /> r <'"�"�^� Assessors <br /> WELL Location 13Q I W. K'e'' 4-1 rem4A/ Cross Street 64mWAt city O, Zip 952t/2- Parcel# D -0Jd-0$ <br /> PROPERTY- kAHF; .- <br /> Owner U,-[& WAFFi!�wa Addressl3ol kl. lfe-►fhwi,v City Lon zip9S7Y2_Phone# "t-39Y-1Z33 <br /> Rq+v eNo <br /> C-57 Contractor CflScA or- 0r,'l?, Address-141L OAu, Cs'rde Ci y caQDavA Zip45'7yZ Lic#7175/o phone# 7114- &55- /149 <br /> Consultant/Sub Cntr A. C. Address 537 SHAW ROA-City S Lic#(08 a zt 7 Phone#'Zaq - V 6 7P/o{, <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> )(NEW WELL 1 BORING (CPT GEOPRQBE, YDROPUNCH, HAND-AUGER, THER*) p DESTRUCTION (choose type below) <br /> OIL BORING# Zj <br /> P-6, 4 0 OVER-BORE. DIAMETER <br /> XWELL# MW < -10 0 0 PRESSURE GROUT <br /> 0'Other GROUT SPECIFICATIONS <br /> COMMENTS: SF,,F �v- SIT A55,0T?0 -Z Zpo <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS /i <br /> *ONITORING HOLLOW STEM DIA.OF BOREHOLE Q ULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: Z <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS �� a� C TYPE OF CASING: 0 STEEL /q PVC <br /> 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL_YC ' TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: KYe 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 'SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS C-r <br /> 0 OTHER:_0 OTHER APPROX. BORING DEPTH 0 'QOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED Al 0 (if YES, list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGR EMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that l have prepared this application and that thework will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable CaliforniaDState Laws. <br /> Signed x___�i/11ryb-L 4_ , LJ�PI`^� _ Title/Company 11g0 FCj' NQt%,AS�Q/ <br /> Print Name Date ! / O 5 <br /> DEPARTMENT USE: ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATEDti ,, D <br /> Application Accepted By Date Issued loll c, C Area 74a <br /> Grout Inspection By nb I Date (7 Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS l CONDITIONS: L 0 Il ld ttlr+ <br /> ACCOUNTING ONLY: AID# FAC# r <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br /> EHD 29-02-001 <br /> 6/22/0471IIIII�yyyyy A .�A co <br />