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San Joaquin County <br /> �. Environmental Health Department SIT E <br /> 304.East Weber Avenue,3rd Floor,Stockton,CA 95202 MITIGATION <br /> ` (209)468-3449 Fax: (209)4683433 Web:www.sjgov.org/ehd UNIT IV <br /> 0Well 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 app nation Is made in compll:ince with San <br /> Joaquin County Development Title,Chapter°..-1115.3 and the 5tandards of San Joaquin County Environmental Hes th Department. <br /> ors <br /> r^hU1one�_aZLPB <br /> MELLLocation ZiP ' h1oan4e � <br /> � 'q��ea�11 <br /> PROPER <br /> Owner __Ad -0 � YTdress �Z5 —' ZiP± <br /> C-57 Contractor /X7) Addss ZP t # <br /> Consutant/Sub CnA& Aod �� ddre5423zj /!�!- iCIN UaZ 9 , <br /> 7 _ <br /> GLS Coordinates:X Y Township Range — Sactlon_ <br /> WORK TO SE PERFORMED: <br /> -ONEW WELL/BORING T.GEOPROBE,HYDROPUNC}i,HAND-AUGER,OTHER*) D DESTRUC1lCN (choosotype be ow) <br /> V- SOIL P-CR1NG a OVER-8CRI:. DIAMETER <br /> �;VLL Q PRESSURE GROUT <br /> []'Other GROUT SP C!FiCATIONS <br /> COMMENTS: <br /> TYPE OF'AML INSTALLATION TYgg CONSTRUCTION gFECIRCATIONS <br /> 0 MCNITCRING 0 HOLLOW STEM DIA.CF 5CREHOLL-,g�L Q MULTIPL5 CASINGS 0 liul'T1-LEVET WELL CAST JG DIA: <br /> OCTRACTiCN 0 AIR HAMMERIDRAfE.N CASING THICKNESS_ n/0 _ TYPE OF CASING: Q STeEL a FVC Q GTI-ER: <br /> (]VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYP=„G SE USED' p AUGZF S 0 HOSE <br /> [j AIR SPARC-J OZONE PUSH PCINT(GP or CFT)GROUT SEAL PUMPED: Q Yes WNo (NQ7,�:MAX]NI1jM FREE-FALL DZ:PTH IS 30') <br /> SGtI BORING HAND AUGER GROUT SPECiFiGAT10NS ,.?k� 'V4 — <br /> II OTHER: T!OTHER APPRCX.SCRING DEPTH rL 5�1 11 i3DL -0 TRAFFIC BOX or Q S"Cv ?IPE <br /> CONDUCTCR CASING PRCPCSED _Of YES,list speclficaticns in cc rnment Section) <br /> COMMENTS. �(6 &A"'r-S C'A)7' S -- <br /> NOT,: OFFSME: SCRINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT ErE:<9VilTS, <br /> 48 WORKING HOURS NOTICE REQUIRED EOR INSPECTIONS. <br /> hereby certify that I have prepared this application and that the work will be done in ac::ardance with San )oat, in <br /> County Crdi ants Rules and Regulations,and all applicable California State Laws. <br /> Signed x Titlelcompany Z --- <br /> Print Name Data <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 136.5 Lin q <br /> _._ <br /> WORK PLAN DATED.' C —. <br /> Application Accepted Hy �`r ' Date Issued <br /> Greut Inspection By Date Final InspeCOon By _ Date_ <br /> Destruction Inspection By Date <br /> •COM DENTS ICONDITIONS — <br /> ACCOUNTING ONLY: AIE* FA11 T_ <br /> PE C00ES FEE INFO AMOUNT RE WTTED I CHECK# RECD BY GATE PERAN r/ SERVICE REQUEST111 I INVOICE <br /> 0 4RI f3 17AZ4 SR#Ill 33ct <br /> C-57 WCC WAIVER_., C-57 Letter of Authorization to sign permit,,.,_Encraochment doc_ <br /> EFTA 29.02401 <br /> 5!22/04 <br />