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San Joaquin County FiLL C <br /> Envi or nmental Health DepartmeRE�F�V F SITE <br /> 600 E.Main Street, Stockton, CA 95202-3029 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.orgAfj 1) 2 2003 UNIT IV <br /> —� Well Permit Application ENVIRONfOE �i [ EAEF!1 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSIf&RMIT/SERVICES <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 /> _7(� AA 1 Assessors <br /> WELL Location QC.. �L Aye-r1t" Cross Street R,\(.A R �c1 City �vcl�,��y� Zip�$Q2o�Asses# D <br /> PROPERTY 'r <br /> Owner �,r',i- n (m C., Address_ 31 R. �Py✓ie.l Hw City`�nls�FeS�rinySZip 4 Q Phone#�bL9'ZJ 35t 32-5 <br /> C-57 Contractor'[5}�v.,er c: b✓:'ll�r�c Address 101(, E. (C-At((,-, / CityAyy, ,y\ Zip92 i Lic# Phone#ltgj3g6 f�SL� <br /> Consultant/Sub Cntr 64-7 S4(JS11c Cc,5,1 Address� ,,,KAyt ZCO City Lic#Q!r1 Phone#?/yfi'?E57 <br /> GIS Coordinates X 360W'01-31" <br /> ,YnL21f ,Township Range Section <br /> WORK TO BE PERFORMED: —lZa IL <br /> -ANEW WELL/BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> $SOIL BORING# IO 0 OVER-BORE. DIAMETER <br /> 'WELL# 0 PRESSURE GROUT <br /> O'Other� LD -tl GROUT SPECIFICATIONS <br /> COMMENTS: a �+ a liS yv�w f1 W_ r� h1w_ v ti <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS rAW-1,J-3 •- DiA EA. <br /> �w-11 ._ '{yD/R <br /> `,1MONITORING HOLLOW STEM DIA.OF BOREHOLE, J� AMULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS Scher O TYPE OFF CASING: 0 STEEL �1 pVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH O WRP2T SEAL''` TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE *PUSH POINT(GP or CPT)GROUT SEAL PUMPED: `S Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> `;SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS t ,n -4c �,f-+ <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH S-B . 7'V 0 BOLTED TRAFFIC BOX or ASTOVE PIPE <br /> CONDUCTOR CASING PROPOSED AI O (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 th' pplication and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Runes/ and R lations,and all applicable California State Laws., / <br /> Signed x 'v Title/Company ��✓Li�"t- f✓(it�vrrb�►� �jtSr�/'f+~`t7�iU �/4txi�r C <br /> Print �►� ih'r <br /> Date /t'- 61-a <br /> DEPARTMENT USE ONLY ��Q� / <br /> SITE MAP IN UNIT IV FILE,ADDRESS: - ��f f a*,y�tIzi, <br /> WORK PLAN DATED: 12 -177-077 P <br /> Application Accepted By Date Issued / 'G • Area Q <br /> Grout Inspection By Date217(-?1r1-4A' Final Inspection By-LAMKIW!�w4m <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 I SERVICE REQUEST# INVOICE <br /> 15o1 g9 2&6 3 sR# 053 I <br /> C-57_ WC -WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc 4N, <br /> EHD 29-02-001web <br /> 6/22/04 <br />