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u:► "-in Joaquin County <br /> ,,o Envirtmental Health DepartrYii'ZlitSITE <br /> 600 E.Main Street, Stockton, CA 95202-3029 ' II"��r MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgo-v`q?g/jehd UNIT IV <br /> «aR Well Permit Applicatiowv/,q0A'. r/ <br /> . .j, <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE it y�T{` <br /> ✓/ ' <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This a'I}plication 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 /> Assessors <br /> WELL Location .'✓�!/ 1`ta;�► 51'-et Cross Street ZJ S"[ City i Zip 1153(,1, Parcel# Z 6 t- 1 70 4 <br /> PROPi ri & Address City !'� ZiPhone# /-/,4 <br /> OwnerPc <br /> C-57 Contractor 1 e_s f�n.C/1 csc. �i�i' 4ddress431��J5 Lt�tir�..e h _City Lip yS7YyLic#�"7`�Ssr�q'Phone# 9!�45y-"KY <br /> ij <br /> Consultant/Sub Cntrr a-/Ceue�� AddressL9Yal9 Ri�a✓'Ss� :✓e City Lic# Phone# 7O-7-`33-43�Q <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROP A -AU E C7 <br /> ') DESTRUCTION (choose type below) <br /> 77) <br /> SOIBORING# s� f1 a OVER <br /> 0 L -BORE. DIAMETER <br /> ice' IIiJ�IhJI IfJPRESSURE GROUT <br /> .►. <br /> 0.Other 1' GROUT SPECIFICATIONSCOM <br /> MENTS,/ /hon r�/Y.s t.. �1 5 /`7 W d � `�!/� /7l✓��f�I /44 4/5 A./Y L/—E ff <br /> ld 15'V I <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> j AONITORING 0 HOLLOW STEM DIA.OF BOREHOLErISQuD MULTIPLE CASINGS G MULTI-LEVEL WELL CASING DIA:Z 4'h_/; <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS e-,(JYO TYPE OF CASING: 0 STEEL XPVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL k d"kTREMIE TYPE TO BE USED: 0 AUGERS ,'HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Wes 0 No (NOTE: MAXIMUr FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS p;,- cc�+►s/t <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 9 CONDUCTOR CASING PROPOSED A.1A (if YES,list specifications in comment section) <br /> COMMENTS: r 6 <br /> 4_ 16 cre&S11- d o..&_j : cwt Z.SFa�. <br /> NOTE: OFFSIT�BORINGS REQ6IRE ACC SS AGREEMENT O� ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Qrdinances, <br /> Ryle an I Regulations, and all applicable California State Laws. <br /> Signed x cam' Title/Company <br /> Print Name ` Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 3+1 E MA a n S+Y-el-+ R ►�� <br /> WORK PLAN DATED,,:: 5 <br /> ce40 ,I 29 3 2. <br /> 1 � 0 D <br /> Application Accepted By L �� ` //li' C tJ/JLv� Date Issued 1116.... s- D 7 Area S� <br /> Grout Inspection By Y(L'-jbrj4_L Yh jam' y Date O-11 -0"7_ Final Inspection By 1)'; &y-.'4, -mak Date <br /> Destruction Inspection By V le_�r;rti me�y�'G Date 7 <br /> COMMENTS/CONDITIONS: r "Mze"I. - Z -3 - - S LW l ' <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3$02 G4,oo d0 20045" ;Z/eW_ 140 -57`1`71 SR# 00-5-2- 1 94- <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br /> EHD 29-02-001web <br /> 6/22/04 <br />