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�o �a IHLE COPY <br /> On Joaquin County <br /> %a Environmental Health Department SITE <br /> 600 E. Main Street, Stockton, CA 95202-3029 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> 0 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 Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> ICY cn"vim Assessors <br /> WELL Location OS COLI %w DV.Cross Street I City (/AUlZip Parcel# 'I ✓� <br /> PROPERTY � � { rta� ( 26fU' @ASH <br /> Owner o npno9Address LP00( bolll�Ioy Cit yaU�Y1n Nyytm Zip /03 Phonney�# q7 Q�-L—�2 <br /> C-57Contractor � /t l� M -Ni]Address� �(11u' P-D, —City lu'�r"{'enMETZipVMLic#TLjSV� Phone#'72S--:31-3-_Q30'0 <br /> Consultant/Sub Cntr&JEU 1 y IH'I /L).XAddress2t'DI Wekgt i-f�, City 4k1dLic# Q l�T.Z/ Phone#'� —ll���—"17�� <br /> I1 <br /> 'Y <br /> Coordinates:X (N L 25 I ,Y 3�421A-C I' Township Range � Ea_S4_ Section <br /> WORK TO BE PERFORMED: <br /> )(NEWWELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> )(NEW <br /> ,SOIL BORING# 3 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0*Other <br /> sn GROUT SPECIFICATIONS <br /> COMMENTS: l�P� L' Ylrw 7Y d vGIwu-A41ve4- .QK1knP11fj <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 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE XPUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes jNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Gil <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS o✓ o fDWf�I I <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH --7V f 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 Ordinances Rules and Regulations, and all applicable California State Laws. �/ �/' / �j <br /> Signed x G(/L�//��' t//� n pj,� Title/Company V tf� Ci eo l(?if, sf .QCnzc -,I- i i CAIM1714 <br /> 14 <br /> Print Name MAC( 6 1 b V'l V 6F Date (/ b 7-&7— <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDR SS: zoO S <br /> WORK PLAN DATED: 1136 <br /> Application Accepted By - Date Issued I 1 y Area <br /> Grout Inspection By Date Final Inspection By Date l <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> t b 1 -9� !a 5�6� � o� sR# 51 G 7 <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD 29-02-001 web <br /> 6/22/04 <br />