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I r�/San Joaquin County S tD camp <br /> VICA.; Environmental Health Department E <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> al �� n X r- <br /> .�0R Well Permit Application � �' '� <br /> Hit � � ��: <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 /> JoWunL,,,2 unty Development Title, Chapter 9-1115.3 and the/Standarrrds of San Joaquin County Environmental Health Department. <br /> ` '753 <br /> Assessors �1 <br /> Wa n Cross treetGod 1iJSn Dr. city _zip�Parcel# <br /> PROPE . 6C�'f �f �� a 5"? AI Edi l V4 4✓e �0 pu'h 9S'3LG � 9-<5- ?- <br /> t 61 <br /> Owner Ad res r&ATA +1&110-Phone#.---­. <br /> C-57 Contractor hm. A"" Address q5D L ��city Zip?90 <br /> Liic# /v,7 <br /> hone# --V-00v <br /> Consultant/Sub Cntr Ryrl� 4— Address5190 M18 9.Sk-A cityri*)mAic#770 hone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> -0 EW WELL/ BORING (CPT GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> SOIL BORING# a OVER-BORE. DIAMETER <br /> 0 WELL# a PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMEN Cil Qd -W NOV- 1'Ytr 1OL <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> [)EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: o STEEL 0 PVC 0 OTHER: <br /> o VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> a AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER: Q OTHER APPROX.BORING DEPTH BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> CIIettr,+rmcb�rn� ►: v,y, p ' r,Q 1 <br /> NOTE: OFFSITE BORING REQUIRE ACCESS AGRE MENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 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 <br /> Print Name 1 Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: I x, i a hf- F i& S} e. �c ag E <br /> WORK PLAN DATED: 9POG <br /> Application Accepted By W&hdaa Date Issued & 11 <br /> J4S '7 <br /> Grout Inspection By Y j!2b_fi 4 ) Mtn 4yA&q Date 2 07 Final Inspection B <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: I - e.� R7 TJ - <br /> ACCOUNTING ONLY: AID# FAC# <br /> LPECODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> 89 974. ov SR# - 491,G9 <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 />