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N� <br /> San Joaquin County 205 <br /> Environmental Health Department �=�� �y SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 9520 JOAOvtN NT MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/e i�IROE?A jtA0AT <br /> \cq ,•,\/ H�A�TNpE UNIT IV <br /> �C1FORti 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 lopmet Tjfje,Chapte 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> -LV �pJ Assessors <br /> x WELL Location Cross Street L City Zip Parcel# <br /> PROPERTY <br /> OwnerAddress QO -'?>bx 'ZoQ`i City Zip`1,5Zol Phone# 71Dq\rl`tC-C>-L4 <br /> CS7 y'�SI�S <br /> C-57 Contractorr�] r.11 Address't SD �--1 . City <l=M t ZipjLic# Phone#�G 2 S��1 -SSao <br /> v5al....� <br /> Consultant/Sub Cntr�lZs (oCp Address21Z1 NCityc �<<� Lic#1±6Sl4s Phone#CqzS <br /> S �Q I <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`I- 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0`Other GROUT SPECIFICATIONS <br /> COMMENTS: Qo ✓lei -Ie n, A— L•-e_ ���sk����� o c 'LesI- <br /> c <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 To'-35' 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 /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONSTrc�'- <br /> 0 OTHER: OTHER Z P Inmos c APPROX.BORING DEPTH 2 0'- 35 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: 1`F EY��o�a�"1� !�5 1l A-V 2 ^k z 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 C e-o� ->k <br /> Print Name '1 sro A '--c e' P I's e\ 2 5 `5 Date Z k 5 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: (t-A-� Ka&o,.-- <br /> Application Accepted By Date Issued a-I q I S Area:l <br /> Grout Inspection By Date t' Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: S�a" �` c�C-" <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED 404WCKf * REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> �� •al &Irt '0' '`j.DD p,StA 2� p SR# DO I I Gi <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 />