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PQuiry -an Joaquin County � Y <br /> �Q•b rti '',•OO <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> N: <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sigov.org/ehd UNIT IV <br /> A<<FOR� 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 /> r 9S-Zj?— Assessors <br /> �& <br /> L ocXn S7b8 N • Hwy -9 ? Cross Street /VONe City T g)&-f a�/ Zip Parcel# <br /> OwnnerGr <br /> PROPECTTIrl ewk/ '7/ .� Address 9-76 AJ <br /> ? Cityips�S.Z'�one# 93t-3 3 y/ <br /> C-57 Contracto V I`N' {�tiress I(J-�. J LP Cit�(� _�P - '65/„one# !6t'O V16 6 <br /> Consultant/Sub Cntr�C vG I'�v/� Address $aX �� CCity�ic# ' G t u f Phone# zo <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> EW W LL/BORING (C.PT,GE PROBE,HYDROPUNCH,HAND-AUGER,OTHER-) Q DESTRUCTION (choose type b low) <br /> ` OIL BORING#_ OVER-BORE. DIAMETER 4 <br /> Q WELL# 7 Q PRESSURE GROUT <br /> Q*Other / /J GROUT SPECIFICATIONS <br /> COMMENTS: Se {�e/,►N9 P Q Nd� .4upt Q a A Gen�roZC <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFLCATIONS <br /> Q MONITORING Q HOLLOW STEM DIA.OF BOREHOLE-j_ Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA------ <br /> a EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS TYPE-OF CASING' Q STEEL Q PVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL-!�f d�l TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> Q AIR SPARGE/OZONE VePUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes Q Na (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING JFHAND AUGER GROUT SPECIFICATIONS - <br /> 7Q OTHER: Q OTHER APPROX.BORING DEPTH BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> COND CTQ/R CASING PROPOSED <br /> (if YES,lis speci�tigns ir},c;gt section) <br /> COMMENTS: SN11IOM /Nt/to.9 / 4' ON VHtjP4 �7L /LoQ� /�/es . <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 acZQ' dance with SarrJoaquin <br /> County Ordina es, Rules and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company © Ll/Al e [�— <br /> Print Name Al <br /> G /t4 y Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: N' 1 Uf 0,-:5 O r to/ <br /> WORK PLAN DATED' <br /> Application Accepted ByDate Issued 6 Area <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 /> SR 0.0 SSL <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit VEncroachment doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />