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�o aU oo San Joaquin County <br /> Q a <br /> Environmental Health Department SITE <br /> y < 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 /> LIFORN` Well Permit Application 2001 MAR 12 PM 2: 13 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUfj%ay i,.:y r,, `;N TY <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work describe lthts Ap'iii62f h"'hi&di b compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environm �IMi:alt 6i0^rte[itT?"1L N T <br /> Assessors <br /> WELL Locationfo`74E. �r bl. Cross Street CityLVI Zip�S_7Tv Parcel# 05_t-)3O <br /> 5_t' 30 -O`, <br /> PROPERTY Sa' jC' `nw, <br /> Owner Vete L&,YE CL-C- Address 147'0 1^l.i�t.S l Sic. K— City LE Zipl S�-qZ Phone# 33-3-340-D <br /> C-57 Contractor O�A4-1nf M•t&MC-Address 90 2- `yj_" 4w City ,� Zip`lrz`�� Lic#�yC Phone#3 Lo+-36 1 <br /> Consultant/Sub Cntr Address City Lic# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> SOIL BORING# 6-5 a OVER-BORE. DIAMETER <br /> a WELL# a PRESSURE GROUT <br /> a`Other - J GROUT SPECIFICATIONS <br /> COMMENTS:di�jAAA tt'_ r! I f <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE 3 0 MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC a OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS a HOSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER: Il OTHER APPROX.BORING DEPTH a BOLTED TRAFFIC BOX or a 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 Ordin Hees, Rules and Regulations,and all applicable California Stade Laws. /�� <br /> Signed t d Title/CompanyV'�Il.0 �i.� e.�.�Ck /N+^( 0• H�A�St>^ + fs,S6 . <br /> Print Name Sr�a fAcIt-o —Date-3. 1'21afi <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: /"��r.�r� , 2,on <br /> Application Accepted By. 141 Date Issued 3��y�n7 Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONSC 4P110 1115-k <br /> ACCOUNTING ONLY: AID# v FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> L01 $�- SR# ()V �. <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 />