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� FILE COPY <br /> �oPq�•"..�� San Joaquin County q JU k'— <br /> _ Environmental Health Depa e> 6 . �, � SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, 'J02 �� 5 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.s' /'Y'`iq+// y�q UNIT IV <br /> 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 /> a6gos s��wl (I A �t y 1 f GCS Zip� arcel#Assessors <br /> WELL Location f ( ross Street `t�Go Cit . . (� Parcel# a46 140-01 <br /> PROPERTY �►��O''` Cotpatw�u�, 6DC31 8ou�wyel �n Rbc $�+n Qawk�n� A 94Sd3 c};LS->e4a- 180y <br /> Owner UPRf-, Address 14S1i}{)4NSonSI-,5{c Im city IZASeu���e- Zip '� 7-Phone# 9)(,-7$9-•SS'o�$ <br /> C-57 Contractor rreGISIVA .Sp ji,A$Address lqffi Sciu}h 60*.s'c. City '9kt6#W� Zip_!WLic#6363&7Phone#SIO-0,1j7"yS'7S <br /> Consultant/Sub Cnlr tJ�AW!g:�IIAC CcASU�Ya�7l�ddress ;1101 ld"9KJ S{ City lX.�r'twr�Lic# Phone#WO- 6636-9I� <br /> GIS Coordinates:X 31• TA3 Y — Ia%. ya3 lqTownship a 500+11 Range S rEuS+ Section 33 <br /> WORK TO BE PERFORMED: <br /> EW WL/ BORING (CPT,GEOP ROY E,HYDROPU NCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> OIL BORING# la clleecl- �k15� -%-Ott )DOtuws 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0*Other / / GROUT SPECIFICATIONS <br /> COMMENTS:�7 (�II1 3D—+��S fyly' = GJ��C•Z��j <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_^-3 H 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS K)111W TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL NA TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0115USH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> R'S00,I1L BORING O HAND AUGER GROUT SPECIFICATIONS ![vPe 'Z-= Alsc.V 1>6t�Aawd <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH_ IS W 60 ;* 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED AJA (if YES,list specifications in comment section) <br /> COMMENTS: Six So'l bOhNc-, ' 6 164 ern ana S X- %.nj 6ti✓iSS &Vy 4-cn. 66 J'� bis <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. <br /> Signed x Title/Company -tOjeOr tep\p%%\isAleorv%ch: <br /> •t'%?c <br /> Print Name Date 7/01 <br /> DEPARTMENT USE ONLY 0007 <br /> SITE MAP IN UNIT IV FILE, ADDRESS: ZFGi�D5 SX(At /AWa4L <br /> - <br /> WORK PLAN DATED: (4.qc) <br /> Application Accepted By Date Issued d Area <br /> Grout Inspection By Date Final Inspection By <br /> Destruction Inspection By Date <br /> Abli- ow <br /> COMMENTS/CONDITIONS: if <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> S,$• -Z>7b�� a5 �� sR# 413 5 <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 />