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'man Joaquin County 0 <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&7115.3 and the Standards of San Joaqui County Environmental Health Department. <br /> AT ; �-I trq/m ,I 1,,,, q /- Assessors '72 /0 <br /> WELL Location 0D5q FA o p 1 Cross Strrleet I.J. <br /> _/Oily 5k'^�'"" Zip `5�Y' Parcel# I l��""•3� <br /> PROPE a IOS IWN(,NO WntOn UIUGJ �Cr,)bv,i P tk q13� <br /> Owner �r5.610 lw�k Address Ciry Zip Phone# 8 <br /> C-57 Contractor Woor�w IIDr- �N��Add�'re/Iss 55oR� /J&Aj City Rl� �is�t zlp9`/�{57Uc# 7/ov1 Phene#�o737y-`/3o0 <br /> Consultant/Sub Cntr S�JVS Ell vi(orlrl AI Address33?0 CgAffwl PWk P�'Cty Ca^rf/+'l Lid15`�Z Phone# s �6'�L? <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> \KNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) 0 DESTOVER UCTIRE. DIAMETER(choose type below) <br /> a SOIL BORING# <br /> 'jYJELL* -I } UPRESSURE GROUT <br /> a OIYUd mw-I <br /> Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ONITORING V, IOLLOW STEM DIA.OF BOREHOLE_:L O MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: u STEEL a PVC a OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT sEAL2t.-41fTREMIE TYPE TO BE USED: D AUGERS a HOSE <br /> u AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ''Yes t0 No (N TE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS 5 I `10 BOLTED TRAFFIC BOX or 11 STOVEPIPE <br /> )]OTHER: n OTHER APPROX.BORING DEPTH '� <br /> CONDUCTOR CASING PROPOSED____L4_(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 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordil anc, ules and Regulations, and all applicable California State Laws.0 �/ <br /> Signed x C L��}UU��I (1 Title/Company C9 T5+ /✓�wk4s E-w nv)�an mbr7.+�r/ �^L, <br /> Print Name Jw"' I,I&j4n, Date o —a 1�D8 <br /> DEPARTMENT USE ONLY 1 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: U O (, <br /> Application Accepted By Date Issued /DO Area <br /> Grout Inspection ByDate 0A 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 I SERVICE REQUEST# INVOICE <br /> SOI F .o 0-01 1 / '7UPU (JK RL Ofi SR# 2e) <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 79-02-001 <br /> 6/22/04 <br />