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*San Joaquin County <br /> r i Environmental Health Department SITE <br /> " <br /> X 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 /> r'<o.. P 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. /w <br /> =i,/TKAL. 4 W-W,4 OF GA Assessors 1�1�3o2m I <br /> WELL Location �1�F SLJ�O�OF/bT Cross Street LfL✓N City fiP�15-K -A"PLip 9S33D Parcel# <br /> PROPERTY Kt�y'RO`,gOCity CAM2i Phone#91G.-4?3S X30 <br /> Owner US lr,- Address7mE4 Y 'r'A�'r'M p TS�30 <br /> C-57 Contracto r .P<a k't^JO Address 960 IJOWIF+'toAD ciryMA�+r. pr/9S$3 Lie#hone# 9 :V-? •SOD <br /> Surf 300 <br /> Consultant I Sub Cntr 1/KS G»RfOR+a71en1 Address 2+970 6arKnNY 6A" CitySoL Lic# Phone# 9/(r679�2m' <br /> 'Sje y ,Township Range Section GIS Coordinates:X <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) O GEST UDIAMETER_ <br /> (choose type below) <br /> drSOIL BORING# [I PRESSURE GROUT <br /> o WELL# GROUT SPECIFICATIONS <br /> O'Other <br /> COMMENTS: .SSa' 4a 1134t+,'ff AdAr' frDIf— LOcdTionj /t,pq,uf•S .f Pas lel o�+S -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE 7-" 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA:— <br /> o EXTRACTION o AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL U PVC O OTHER: <br /> j,R <br /> POR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS [I HOSE <br /> SPARGE/OZONE�USH POINT(GP or�GROUT SEAL PUMPED: a Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> L BORING o HAND AUGER GROUT SPECIFICATIONS B�nTb�"� 5111 <br /> Q OTHER:_0 OTHER APPROX.BORING DEPTH �J�S a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (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. <br /> Signed x <br /> Title/Company //ACS <br /> Print Name � Data <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: / <br /> p o Dale Issued 7151 e4 Area <br /> Application Accepted By '""u'L�r <br /> Grout Inspection By <br /> Date b(o Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> 11 ACCOUNTING ONLY: AID# FAC# <br /> CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> a9� ; b'9 8� " � �YaSy rJK S of sR# <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 />