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ha �u!N co �an Joaquin County <br /> i Envii uZinental Health Department SITE <br /> { 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> ' (209)468-3449 Fax: (209)468-3433 Web: w,.i-A,.sjgov.org/ehd UNIT IV <br /> COPYt,F 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 /> Ziaa 4De,!< fi Assessors <br /> WELL Location -t� Ma , )t• c' Cross Street 'Vj City Sited<i o: Zip c1926& Parcel# yt <br /> r S" Z!/0 7 <br /> PROPERTY C�� OT Sia LlGiz�-. g.2 S /V. Cl Do r-4A <br /> Owner i4� Address CitZip • Phone# /76'. -2 <br /> C-57 Contractor At.+V:"e..aha, Address Zip ci`Z - Lic# Phone# <br /> Consultant/Sub Cntr ALe. Address City S clerk->t Lic# ifS! Z Z 7 Phone# �z�4�r(C--7-Iec,(- <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ',NEW WELL/ ORRIING (CPT,GEOPROBE HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> ;SOIL BORING# 3 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0 `Other p GROUT SPECIFICATIONS <br /> COMMENTS: i•„r , r.CL- sr l YX ,no-,` �. 5 ._�L. Sicl� n� �L'Ic.,F� _� i2e //eir%�,c c�,. e•-,� mac:✓:,� G�f�c�� ! �1— <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE .LtL 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: a <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: .,/ <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Lil C' TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 'R-PUSH POINT GP-or CPT)GROUT SEAL PUMPED: 0 Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 1191- 1/Ir 1i_i�c• c"��, -f <br /> '0 OTHER:_0 OTHER APPROX. BORING DEPTH 1 14 S` 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 /> Signedx /' �� Title/Company <br /> J <br /> Print Name �T�` C G a t�,�c,� Date <br /> DEPARTMENTUSEUSE ONLY r <br /> SITE MAP IN UNIT IV FILE, ADDRESS: Sc u-f�i ,S,i�e nT -,2 D l� 4 '6 10'..k, 6 T �l:n f ji eL4 1 0 4 <br /> WORK PLAN DATED: 11 Fehr m a r�4 �2 G 2607 <br /> Application Accepted By t-6 r;Cf- _. Q+/� �i1 Y- 22 Date Issued $ 17 Area 1 . <br /> Grout Inspection By VI i �r r`,�: rn:''t l' ^�Il k Date Final Inspection By �j cab r ml�il� Date '7 - 1 3-(J 7 <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: ,7-f - .*7- fl fn •-` 'n. ?C'-"i -1,e - ftj "1 3-0 rr d' <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3$03 28S 0 ��• �z7 2S73� <br /> 35701S R# <br /> 3COS�j s/ <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 />