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�o u San Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> �rFORN`P Well Permit Application 1007 MAR 12 PM 2% " <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUg% T <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described` *114 a0.06atfoh'is Nddd Ia compliance with San <br /> Joaquin County Development Title, 1C,,hapter 9-1115.3 and the Standards of San Joaquin County EnvironmJ15t6I4,I6a1tWC6eIi0tnlekltT i`ii N T <br /> 4O 4 4 C. Aax Lr'• c'- L Lo I., Assessors S -13'0 —O`, <br /> WELL Location �'1 Cross Street �Ta�`16y� City Zip `ff� Parcel# O� <br /> PROPERTY (Ia` Joy `nk <br /> Owner Va� x,41& LL--C- Address 142'0 111;k l Sic• K— City LE Zip4SZZPhone# 33F- 4� <br /> C-57 Contractor t73 AA41f M k kb(-Address 6)0 2- J V4 L'+;4 W City l,r A-: Zip`lf?-40 Lic#WTQN Phone#71 too <br /> Consultant/Sub Cntr Address City Lic# Phone# <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 /> $SOIL BORING# (gyp v\�( ow civ (o=$ ' R 6-5a OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0.Other GROUT SPECIFICATIONS <br /> COMMENTS:]�1l16�L, <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 3' 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 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 /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: tl OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <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 Ordinprices, Rules and Regulations,and all applicable California State Laws. <br /> Signed x Title/CompanyPeb ed <br /> nt r / / S-r, --5 <br /> 56 <br /> Print Name Ab( t c e,o Date 3'l 2r a fi <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ,,, <br /> WORK PLAN DATED: <br /> Application Accepted By. U Date IssuedT O 7 Area <br /> Grout Inspection By lk mof4f Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONSC� . ? <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> c� 01 SR# �n <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 />