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San Joaquin County <br /> Environmental Health DepartmentSITE <br /> r. <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 . MITIGATION <br /> (209)468-3449 Fax:(209)468-3433 Web:www.sjgov.Wehd <br /> Well Permit Application UNIT IV <br /> "' "- <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 /> WELL Location i"l"` SOUA ��I�rAM Cross Street 5+p(�j Assessors <br /> PROPERTY �J ) C��' Zip .��� Parcel# G65' o3o-ID <br /> Owner -r)V 04LL1 �oyt Address 13a,'. Jcv,gm, , „ , <br /> 7 city C A^ Zip 55 GO Phone# kO-453-SSh(o <br /> C-57 Contractor CQW u%14Ei _ Address302 OW( �itr Q (0.k /� 6 8- 6 <br /> -!! T� '' /n� 3330 11 Cih'-- °��""--Zipy57`iZ Lic#717?�1Q Phone# 6-3 �/ y <br /> Consultarrt/SubCntr��rcry5(^HviroKvti�t/�1_kAddress 6NAW[i Kpr. - 55D Ca.1tj� �1g(FZ <br /> City ParK Lic# Phone#S3O-G7(p- a0(,'Z <br /> GIS Coordinates:X 'Y Townshi <br /> P Range Section <br /> WORK TO Be PERFORMED: <br /> `R,'NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) a DESTRUCTION (choose type below) <br /> a SOIL BORING# <br /> DWELL* ^!-�j�SC4`-+i r 5(t�-7� t ` � fj�u r 0 OVER-BORE. DIAMETER <br /> a*Other iZ/ 71 A9al.L ldtl 1i a PRESSURE GROUT <br /> COMMENTS: GROUT SPECIFICATIONS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ' t"9kd J d -f 9 9jV�j <br /> (MONITORING `HOLLOW STEM DIA.OF BOREHOLE <br /> a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL a PVC D OTHER: <br /> D VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS a HOSE <br /> a AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING bJ-IAND AUGER GROUT SPECIFICATIONS <br /> D OTHER: n OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> / CONDUCTOR CASING PROP SED <br /> COMMENTS: �� stt r r 3�s C^ q , / (if y�,list specifications in.l'j ,mment section} <br /> �'� 1 { f��1�a � (if/i�`! Jf✓ 1 �5 :�� -1.F) "ES'/ S f �� S.Z Alf����14. <br /> 3 <br /> 35- <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. f <br /> Signed )ttlW_,�i j/7 / Title/Company(?")F$i .51"5 Fnvitortys � r <br /> Print Name S U I�t.nSQr fl-Z7-07Date_ <br /> _ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: /�Z • <br /> WORK PLAN DATED: <br /> Application Accepted By_ � � �i✓�J Date Issued Area <br /> Grout Inspection By Date Final Inspection By !�� �tn Dale <br /> Destruction Inspection By Date - P (--- <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> jjjT <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# IT/SERVICE REQUEST# INVOICE <br /> 7. <br /> C-57_ WC____WAIVERC-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />