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.ri <br /> San Joaquin County <br /> _' ° HIE C09 <br /> Health Department SITE <br /> WPOINN 090 er Avenue,3rd Floor,Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/ehd UNIT IV <br /> FEES 1 5 "'0 Vell Permit Application <br /> UIVp�IIRg[�Ott,,��N�{�f���EyF}ittYNA}II iE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to'S#r1•,I�'ddrl lh'Cbi 61' Yor 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. �irATj' A/syT- <br /> ,rrov (Ioeril Hjo, ,Ar f1 Assessors <br /> WELL Location 31'1'2 NsAIN N'"'tW yt Cross Street~F' lA.l'E City /rOW-7"Al Zip yfzLZ Parcel# /p Os'- �✓ny <br /> PROPERTY ,/ Sj 17.1' Zi /�B Phone#(�� W ,tlpoo <br /> Owner !AN Ss.s�.%r GsayTj" Address /gp fr/+/.�Gr/V✓ /� Ciry p <br /> C-57 Contractor We FxAprATImW r r AaAddress 9'10 --"A"MA0 ?I,& City TA.Mo,ef MZip r"Ar Llc# 'Z�3ph6e# /!M' P7�-1"" <br /> AAdrNO <br /> Consultant/Sub Cntr SEe"or ,T,rT. "We Address?//7 A'i2s 0 srf1"Ciry ci o, Lic#Ef1`1�,� Phone#/>// fEX <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: )Arf[LJ <br /> 0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 'DESTRUCTION (choose type below <br /> U SOIL BORING# $'OVER-BORE. DIAMETER R'" <br /> D WELL# U PRESSURE GROUT <br /> U*Other GROUT SPECIFICATIONS <br /> COMMENTS:. �Gl�s �� �y 111A1-AO -_ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> `MONITORING ffP0%9WS1k9M DIA.OF BOREHOLE_ O MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA: <br /> U EXTRACTION U AIR HAMMMERIDRIVEN CASING THICKNESS . TYPE OF CASING: U STEEL U PVC BOTHER: <br /> U VAPOR U MUD ROTARY . DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: U AUGERS U HOSE <br /> U AIR SPARGE/OZONE U PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Byes U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> U SOIL BORING U HAND AUGER GROUT SPECIFICATIONS AiEAT <E.ME.lrT <br /> U OTHER: n OTHER APPROX.BORING DEPTH U BOLTED TRAFFIC BOX or U STOVE PIPE C <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: Gn L'l/IMit-,( .r nL '/ -- <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. y) <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. J <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 and Regulations,and all applicable California State Laws. <br /> Signed x Title/Company f��ff 6EdlOA/tT / Is`co.� 1'.rTEA'.YATrO.a/1,C I.Y� <br /> i <br /> Print Name A'� ��lf.�. Date -�d/OS <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 1 l C� r, It ti Cl <br /> WORK PLAN DATED: -4-1;f 10 , 2 nn 5 <br /> Application Accepted By i^e%-� _ '�� I _ Date Issued 37 In`r Area <br /> Grout Inspection By ��-^�'q� Date _�' Final Inspection IB �A,"J�gL Date Y <br /> Destruction Inspection <br /> COMMENTS I CONDITIONS: C �n r C 0 C i i c t <br /> � INk <br /> ACCOUNTING ONLY: AID# 4( F <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# PERMIT/SERVICE REQUEST# INVOICE <br /> 3s C-o2- C'C' CSR# it I <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 />