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�P. �!. c. *San Joaquin County 0 <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> fr�btz Well Permit Application <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 /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location POS f.'SF'10.�C, 905 V47A.QrpCross Street T= S City �.PrTH2pp Zip 4LS350 Parcel# N/Q <br /> PROPERTY <br /> Owner U.S. 14r�yf Address 256a7Chrr5niekA.City Zip- 37(. Phone#(x091 839-41212 <br /> C57 Contractor NA Address City Zip --ILic# Phone# <br /> Consultant/Sub Cnlr en r4ecvw erVrrbM eArA.l Addressf -7 Suw dL✓ n City R4rJ c. 0 Lic# /v�Phone#J91b) SS2179Z <br /> wa A � M , / brt'o 12,10 or !.t <br /> GIS Coordinates:X 6 Szb&8'0 n,E ,Y 32.IM/V ,Township Is <br /> Range �� Section Z� <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) A DESTRUCTION (choose type below) <br /> ILSOIL BORING If L N4rJ0AU(QL- DOVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0.Other )rGROUT SPECIFICATIONS /lmf CeMej rj- <br /> FRrE Fi3i-l. <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_,TL a MULTIPLE CASINGS B MULTI-LEVEL WELL CASING DIA: ti/44 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS /JI/A TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR o MUD ROTARY DEPTH OF GROUT SEAL IID' TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes A No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING HAND AUGER GROUT SPECIFICATIONS FREE—EALL <br /> 0 OTHER:_n OTHER APPROX.BORING DEPTH 10 1 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NO (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 Ordinances, Rules and Regulations, and all applicable California State Laws./ / �7 ( M <br /> Signed 2!1c �ad�Ct / Title/Company EA VrrOKyC;t4/ !rJeSSIe1JM, e,2l•t <br /> Print Name M 0'r K t l c ceZ5 Date <br /> DEPARTMENT USE ONLY y <br /> SITE MAP IN UNIT IV FI E, DRESS:1 S0 � leo-l!'� k4 G IPA /-(l�O�l9/) p g C() <br /> WORK PLAN DAS <br /> : Ct Cc 0 <br /> �I C7 <br /> Application AccepteDate Issued -7(31/0 / Area 1 <br /> Grout Inspection By Date 2';10'7 Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: Al Or R 6 o 5' L <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> f01 elcp DO✓ 330�� jdlL ! 3l SR#p0>/�/C�7 <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 />