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*an Joaquin County ORECUVE- <br /> EnvironmentalPealth Department SITE <br /> 304 East Weber Avenue, rd Floor, Stockton, CA 95202 FEB 4 9vfl'fFGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> gkip a�. ENVIRONMENT ARI IV <br /> Well Permit Application PERMIT <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 aadlhe Standards of San Joaquin County Environmental Health Department. <br /> w' t�Jaslatn ion f- Assessors <br /> WELL Location §2 -I- Of Shck+on ross Stree av `y City _,_Zip Parcel# /y5-D30-010 <br /> PROPEY <br /> Owner l0r+ Df C•1Ork Address cVO I W.WQS t SJ .Cnity S� Zip Q Sa01 Phone# aoq - " 6 <br /> C-57 Contractor. CQ,JS(,A- / 1 dre > <br /> Consultant/Sub CntrSEWS 1n4¢.mCfior�l nC Address 301`70gprc )MC <br /> ity, t14Lq Lic# yygS Phone# `I/6-136�-O�C9p <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> XNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> ()SOIL BORING# a OVER-BORE. DIAMETER <br /> �f WELL# W-ZO; C OW80 ()PRESSURE GROUT <br /> 'Other 5"C- GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING D HOLLOW STEM DIA.OF BOREHOLE 10 p MULTIPLE CASINGS R MULTI-LEVEL WELL CASING DIA:-19--!'ft <br /> p EXTRACTION o AIR HAMMERIDRIVEN CASING THICKNESS GCh 40 TYPE OF CASING: O STEEL APVC O OTHER: yyy9 <br /> O VAPOR 0 MUD ROTARY DEPTH OF GROUTSEAL Ib-19 qty', 1.TREMIE TYPE TO BE USED: OAUGERS O HOSE <br /> a AIR SPARGE/OZONE U PUSH POINT(GP or CPT)GROUT SEAL PUMPED: )(Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> u SOIL BORING o HAND AUGER GROUT SPECIFICATIONS N¢tk CCgyn} <br /> a OTHER: OTHER S-,ny t. APPROX.BORING DEPTHZS- I20 BOLTED TRAFFIC BOX or STOVE PIPE S <br /> CONDUCTOR CASING PROPOSED (if Y�E .list specifications in comment section) <br /> COMMENTS: �LK*o,-Lvq CDyiduc z%-C061yt61 f0 I2C IV61 Nec OYVI sU.V C{Ce <br /> TD IS'gbcyE bC �i Ct{h, PA <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 @nd Regulations, and all applicable California State Laws. <br /> Signed ,2'�� L Title/Company ` tC�eOIwISL-7�� S�CCSZ .� <br /> Print Name W d 15I Date �ry 3/dam rt <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDR SS: O L( <br /> WORK PLAN DATED: /012.SU2/ <br /> ^^^�� 4`77 <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date ( Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 29•CJ 87" 8� (�/�-2� N 6S SR# 90 //.3 <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 />