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• 0 FILL <br /> o. . San Joaquin County <br /> ����oV <br /> �.•_. so <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 JAN 1 I200 <br /> MITIGATION <br /> MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.o'M i <br /> `� ..........�" OPIMENT HEALTI�NIT IV <br /> Well Permit Application PERMIT/SERVI <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 co ance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. ]� <br /> WELL Location al Cross Street -d/ City A("o Zip Parcel#Assessors � �Q'7 <br /> PROPERTY <br /> Owner r.4n Ce{„ P %r Address City a6&1__n Zlp Phonne*Vl <br /> C-57 Contractor&a, SPAVZA ddressloy—& �( &r City p�J �� � -� Zi (?q Lm#p &/O ,7 L yj�- <br /> II1- ''rr �L.(VYn¢t� �Pt� 3y 39) Phone# <br /> Consultant/Sub Cntr hl'Q err Addresses Q ! <br /> OD P(JrIIl�f�_City t* Lic# Phone# <br /> GIS Coordinates:X ,Y ,Townshi <br /> P Range Section <br /> WORK TO BE PERFORMED- <br /> %-4 WELL 1 BORING (oCPT GEOPROpBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> (_ SOIL BORING#�f� T,,Ms/7-/� DOVER-BORE. DIAMETER <br /> 0 WELL# <br /> 0*Other0 PRESSURE GROUT <br /> �• <br /> COMMENTS: Jo,`I f:T,r; GROUT SPECIFICATIONS <br /> J• "I- G'M <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE. t 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: ✓ <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS �p OSE <br /> 0 AIR SPARGE/OZONE RPUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS , f <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 7b_-5Y- 0 BOLTED T FFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED—��—(if YES,list specifications in comment section) <br /> COMMENTS:—.,C-) / 6 'tn\ ft ) f1 1' ,t 4 *"k. ; g r4r Yc <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 O�n�R�a Regulations, and all applicable California State Laws. <br /> Signed x �f�j an <br /> Title/Compy C„A— "r 02 a- �, <br /> dq ��j f '6-Tp-I l.�l <br /> Pdnt Name Hrx�Cwo/ Ra x+01„ Date //VD 6 <br /> EPARTMENT"�USE <br /> � ONLY <br /> /gy..__/IS <br /> SITE MAP IN UNIT IV FILE, ADDRESS: CEG T r[ii{ /� Syt— <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By ate Final Inspection By ^' "' - e G <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RREECJ'D'BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> SR# Q CJ 7 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc !t/ <br /> EHD 29-02-001 <br /> 622/04 <br />