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FILE COPY <br /> opq�'�.,c San Joaquin County YM�� <br /> Environmental Health Departmen�eCC\/EU SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br /> (209) 468-3449 Fax: (209)468-3433 Web: www.sjgov.oSfeWd 200 MITIGATION <br /> .QgC'F.oRN�P <br /> UNIT IV <br /> Well Permit Application SA�NVRONMEOA <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE IS400-VO DEPARTMENT <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 /> !�}*�°/�' I�IYfI�Ir/L'I % Cross Street '�Z ��L t � Zi - Assessors <br /> WELL Location y p �!� Parcel# <br /> PROPE�TY (p ��j fq3-60 -,17-- <br /> Owner <br /> j}� —Address PO, ROK I�) City Zip Phone# <br /> J "'�� / 9�, pin <br /> C-57 Contractor t +,V t✓�t/; L��'�tin/ll� 1�A►ddress AZ -2 iniu`"� tv/t�J City`_ Zip �M Lic#4 Z' hone# (6 00(C <br /> Consultant/Sub Cntr ���L% l�fr'/�V, Address 57 4K�"WVYVA City Af Li Phone# t _ <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> *NEW WELL/BORING (CPT, OPRO , HYDROPUNCH, HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <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: A/,4— <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: /W <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALEAL Q TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0:�USH POIN O(Gor CPT)GROUT SEAL PUMPED: 0 Yens )a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> OOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS A»r1u� <br /> THER : 0 OTHER APPROX. BORING DEPTH /Q ( 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED /LJ,4- (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 Or • nces and Re ulations, and all applicable California State' Laws. f� <br /> Signed x Title/Company �/, /`` '/Ke <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRES Z3 ✓� <br /> WORK PLAN DATED: 30 G <br /> Application Accepted By Date Issued Area 6 t 1 <br /> Grout Inspection By Date 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 /> jo sf3 �/SS �� sR# DD /o l <br /> C-57_ WC=WAIVER C-57 Letter of Authorization to sign permit✓ Encrment doc ti <br /> EHD 29-02-001 <br /> 6/22/04 <br /> a <br /> i lw <br />