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REM <br /> W� - �... . WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> APR 0 2 2004 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ENVIRON /SE i ICES 17 (209) 468-3449 <br /> PERMIT/SERVICES <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 Tile,Chapter 9-1115.31 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location 510 �, /I/ra O�ia 5-f, Cross Street CitySTOL.K.l�Y1 ors <br /> Zip 1SZo i-Assess 139-Z/O-O-� <br /> PROPERTY pp <br /> Owner CSU Address4po O.Me t rSAVr'evrrt 8CityLo9x`4 Zip 0802 Phone#S(o2-9Sl-`�(20 <br /> C-57 Contractor VV✓Ot1LlC ZvIC. I Ave. 5T— .I 405 <br /> Address Zllo Ai4iks VQ City ea ro Zip94543Lic# 924 Phan e#S/6-Slag-}L?{e <br /> 188 Gr.a.+1c Wcs i✓� <br /> Consultant/Sub CntrCOvIjoY AddressL Ciry$hocie�-o to Lic# Phone#,21Jr{-23T-O SIB <br /> GIS Coordinates:X y ,I <br /> ,Township I r�iorf'In Range (a E0.S+ Section Z <br /> WORK TO BE PERFORMED <br /> �IEW! <br /> WELL/BORING (C�IPT1, �EOPROBE HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> ,8.'SOIL BORING# 3 TO'!� <br /> 0 WELL# 0 OVER-BORE. DIAMETER <br /> 0.Other <br /> PRESSURE GROUT COMMENTGROUT SPECIFICATIONS <br /> S 'Pro Rood r,.-T"'^^c. isc i4,c.o� v� S,r Scspi Do �rK a K P S <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATI <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE Z' O MULTIONSPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION n AIR HAMMER/DRIVEN CASING THICKNESS NA _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 PUSH POINT(gar CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> ',SOIL BORING p HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_ n OTHER APPROX.BORING DEPTH 2 5 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> II CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: B r L �O 25 loci,is <,c I ' I 5 �"7 ' / <br /> NOTE. OFFSI I E BORINGS RE RE 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 Ordit es, Rules and Regulations, and all applicable California State Laws. II <br /> Signed xS� Tttle/Company Co o✓ r' Q.c.� o t l <br /> Print Name B. r7T- Date Z O <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS:_ <br /> WORK PLAN DATED: ,IQC( <br /> Application Accepted By ` 1 Date Issued <br /> A ea 7 <br /> Grout Inspection By Date LL4 0 4 Final Inspection By Date Q <br /> Destruction Inspection By �'--- Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> .24lel (� (��� # 3?c( '3 <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit_ Encroachment doc_ 9/30/02 <br />