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�1F <br /> San Joaquin County <br /> ma& Environmental Health Departmeq . �� SITE <br /> < 304 East Weber Avenue, 3rd Floor, Stockton,CA 9& j 3 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.s*bgR% hd 2005 UNIT IV <br /> ` Fo Well Permit Application N4flT�FN7.�E cry <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED S <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 /> ( - // �j ,�/ Assessors <br /> WELL Location�SRe/6C (/U 4e� ,4;ori�i/Cross Street. / Chy ZJp ✓20 3 Parcel# . ,I-0 001 <br /> PROPE TY ��'''' ���� <L <br /> Owner r o Sfv CKh� Addmss ,vjA,,VJtn/�CitySikC Zlp2f,2o'J Phone# ��o'Y� Y�✓— 62` — <br /> C-57 Contractor PC Address��,3SV //,7)1X1'�,Olx cityA�aLp ✓�4Z Lic# 10063 Phone# /�/ LLd_3`190/0 <br /> Consultant/Sub Cntrfk /�L'/L2 &V WC Address O,70Zjgole A City �Uc# Phone# ss_T��� <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER`) D DESTRUCTION (choose type below) <br /> D SOIL BORING# D OVER-BORE. DIAMETER <br /> 9 WELL# /.s D PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 'MONITORING—.S D HOLLOW STEM DIA.OF BOREHOLE D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA:1l N <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL $PVC D OTHER: <br /> D VAPOR /2 D MUD ROTARY DEPTH OF GROUT SEAL 3 I TREMIE TYPE TO BE USED: D AUGERS Ij HOSE <br /> Jr AIR SPARGE1 OZONE I PUSH POINT(GP or CPT)GROUT SEAL PUMPED: D Yes ONO (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> D SOIL BORING D HAND AUGER GROUT SPECIFICATIONS,0IbAt Z-3 r gsgo,e ,CCdNL�/h(.t L/�'E ie,F Be+�N)L ICrr) <br /> D OTHER: H OTHER APPROX.BORING DEPTH /7/ D BOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED krO (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 Ordina R es and RJdrpu�lat/ions, and all applicable California State Laws. /f _/ <br /> Signed =J /]V,v�"u� l Title/Company �Yll L.'�! '/ee / Wmc <br /> Print Name LGfr(O �l a �to <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> /CUP— <br /> c2c�-St Qpm., tu. tl 4Ac.I i 2ooy <br /> /d'K <br /> Application Accepted By M3"-x Date Issued S/� (a/0S Area <br /> Grout Inspection BDater/OSS 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 DATa242'0­33 _7 VICE REQUEST# INVOICE <br /> Gz?xv F7- 8F ( - 3-7-2 0 � Sl <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 />