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San Joaquin County <br /> Environmental Health Department SITE <br /> " 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax:(209)468-3433 Web:www.sjgov.org/ehd 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 /> �nr, <br /> WELL Location SII'j E , i�lflnh &A - Cross Street V_)AA�cv City6(rjbl_' Zip AssessorsParcel# 155`16D -- O-} <br /> PROPERTY <br /> Owner Address 9eyrl(4 r,c. City_�✓.u-.}wrodZip����J Phone# <br /> C-15/Contractor/441 Address 'b7—Ju"f�City Loaf Zip%!4OUc#telo96A Phone# ✓'le"a--3'I"'Di <br /> Consultant/Sub Cntr Address City. Lic# Phone# <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING {CPT,CEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# S -o L2 0 OVER-BORE. DIAMETER <br /> a WELL# 0 PRESSURE GROUT <br /> 0`Other GROUT SPECIFICATIONS <br /> COMMENTS: I/�.0..v�r�. zvi�•✓ St rnX. &a=f44n <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMERORIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR g MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 'SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: A OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <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 A'fX.���i� Title/Company /VPnj 0, r-1'v..N,.1 ,Cy� <br /> Print Name A-Wq 0./ c-cam Date -I- fl to�- <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADjDRESS:5-//3 i M a moi+ <br /> WORK PLAN DATED: `f <br /> Application Accepted By Date Issued g12`-/�V? Area 92 7 <br /> Grout Inspection By 41 f Date f $- r7,' Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> o(`l of 8� $ {foto 14 o SR#ooS03 <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 />