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San Joaquin CGunty . <br /> Environmental Health Department' SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 <br /> MITIGATION <br /> (209)468-3449 Fax:(209)468-3433 Web: www.sjgov.orglehd- lNIT IV I <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 9 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 applioatlon is made in compllance with San <br /> Joaquin County Development Title,Chapter 8-1115.3 and the Standards of San Joaquin County Environmental Health Department. �7,r�7-�Do.O� <br /> /+V�. CrosLOSvtet`xtC/kF bx+`v City f Zip al� Prices rs�z l 9� <br /> WELL LocatlonSDD W �p[ �{J� u L� <br /> PROPERTY LL y t Dr aD-07 <br /> Owner. r i�I Address Boo &x p City Fni r Oak-5 Zip �2S Phone# <br /> C•57contractor.Woo4Wayi Driij%Address550 �'VI 1�Lt City ,o (/, Zip�f�571 Lic# t0 Phone# 7D7,37�p <br /> Consultant/Sub Cntr r trS EIui,"",W�Address +0 64k D, C ClipwmPLl b'Z Phone# " (o-24 s <br /> GIS Coordinates;X 'Y TownshipRange Section <br /> +MRK TO BE PERFORMED: `_L <br /> p NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHt=R,) X6ESTRUCTION (choose type below) <br /> 0 SOIL BORIN # OVER-BORE. DIAMETER <br /> a WELL# m��r -WRESSURE GROUT f rr <br /> 0.Other GROUT SPECIFICATIONS nPWT COMMENTS: /k S Lviceo ek-tAatr�Q� <br /> i <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS (—'et' 6404 [) <br /> '"ONITORING 'HOLLOW STEM ❑IA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTtON p AIR HAMMERtDRIVEN CASING THICKNESS TYPE OF CASING: 11 STEEL 0 PVC <br /> 0 OTHER: � <br /> 'VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: flAUGERS 0 HOSE, <br /> ),AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: *Yes 0 No (N TE: MAXIMUM FREE-FALL DEPTH 1&30') <br /> a SOIL BORING 0 HAND AUGER GROUT'SPECIFICATIONS Amt('a sy Q� <br /> I1 OTHER: fI OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or a STOVE PIPE i <br /> CO DUCTOR CASING PROPOSED (if YES,list specifica'ons In comment section) i <br /> coMwieNTs: Q .��� d tU-�� 1�J- Vw- - -2 PPW-An IglL J 7 l"Llal�£1,40 i <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS, �wq <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 Sue <br /> I�V��fn:1pp Title(Company_ �9�1 $i5� �^>7lAtsf�,Iyi�or3�rytc.c`ti/1T-C, <br /> oo <br /> Print Name,54671 rJ r ><i n�vr _ _ Date, <br /> DEPARTMENT USE ONLY l <br /> SITE MAP IN UNIT IV FILE,ADDRESS:_ <br /> WORK PLAN DATED::, Sd�r, {L�I LUIJ <br /> Application Accepted By Date Issued► .d Arw. <br /> Grout Inspection By L'G -Gds Date L 4 1 n Final Inspection By -I Date / <br /> Destruction Inspection By Date I` c <br /> COMMENTS!CONDITIONS: /K w -7 ta'763 r✓_1ly, ,4C.9 jt, z pia t!� C 1 '7:3 Z <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT t SERVICE REQUEST 0 INVOICE <br /> /-7-7. d 3 SR#6o5­b - <br /> C-57 WG -WAIVER_._ C=57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6122/04 <br />