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o> '^'��• San Joaquin County <br /> 4 2p05 <br /> Environmental Health Department SEB SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 9520 3pAa0IMEN1 L MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/eW1AO"ppMMEW Of UNIT IV <br /> �P �e05VA <br /> Well Permit Application <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 De lopme t Title,Chapte 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> - 46O 1 Assessors <br /> k WELL Location Cross Street n n RSR L City Zip Parcel# <br /> PROPERTY <br /> Owner -s { —I-k�^ Address1�'� 13ox "Lo g`1 City Zip`IS201 Phone#�2oq��'i�-o2`i 6 <br /> CS� �t'gS tb S <br /> C-57 Contractor��j !Dc-: Address'I SD I�a t �.� • City c( t Zip 9 ;Lic# Phone#- 2 S)ail 2,-SSa.o <br /> Consultant/Sub CntrjZS Cocp Address 2121 N• �� ty�a 1��} <br /> 1•�oc�.a Ci c �<<�- Lic#1;4S16s Phone#Cq1S `13$-yI(�'o l� <br /> S �c SLD 6 •\ �Q l <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# 1+ 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: 1Jo Ae,.,i ..4e -, 4,A o r A-c5 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 2a'-3S' TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ASOILBORING aHAND AUGER GROUT SPECIFICATIONSTre--', c- a -O-Jr .3I .11-1 �c-rhoA"�c <br /> 0 OTH ER:_V OTHER I- p In.s APPROX.BORING DEPTH 2 o'- 35` 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: 14 Q e I, , 1 4 ick 20' 3 ^k S <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 Re lations all applicable California State Laws. <br /> Signed x Title/Company (ae_o`o I;->kk I F nn <br /> _2S P <br /> 14 <br /> Print Name sro .A w e_f GJ\ S1d1, `5 Date 7 k S <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: 11/ U o? a-,� E <br /> Application Accepted By aknA� Date Issued q I 0 Area ^� <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date / <br /> COMMENTS/CONDITIONS: 8" <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED ZHEC" REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> Z� •�1 $9`� g�.a o �rtSSR# 00 1 I ct <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 />