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p PgUIN\CO n Joaqui,; county. �oo �m����, J <br /> Enviricental Health Departi� i I <br /> < 304 East Weber Avenue, 3rd Floor, Stockton, CA 9R0; 1 12005 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> cq�rkoR� P ENVIROWENTIHEALTFi <br /> Well Permit Application PER^AIT/oERJICES <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 /> DD 1� PA��Pf� Avt, _ Assessors <br /> WELL Location 7I /ACl(9l. AVQ• Cross Street£ bj'Anrcdi AO City S/at:Klon Zip `iSZa7 Parcel# <br /> PROPERTY F- <br /> Owner MI'Kt. MAN4S5ttaAddress Iygo MAAAPT_City LDn1 Zip957yZPhone# • 65-a/ 78 <br /> CASLAOEAfacrlo <br /> C-57 Contractor brrllrAg Address 9b32- OMec Cr'mlt City CafOovA} ZipSk7VL Lic# L25'/a Phone# "94 �O3F1�lIV� <br /> Consultant/Sub Cntr A .0.I= . Address SS 37 SAA w RD• City SToc.l(Tt.�L #� <br /> ic#650 2 2 7 phone .ny V b 7/o o <br /> GIS Coordinates:X 'y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE, DIAMETER <br /> WELL# W 1 0 PRESSURE GROUT <br /> '[JOther GROUT SPECIFICATIONS <br /> COMMENTS: 5Q4L iko( K P�HN Ad�CdV'W -DA—fRi) 7-IMA(Yµ�ao-3 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORINGOLLOW STEM DIA.OF BOREHOLE ®" 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> Sc elv)t DOTHER: <br /> EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS 4 o TYPE OF CASING: 0 STEEL PVC <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL IL' TREMIE TYPE TO BE USE : ,YAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Ygs No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS orf An.D Thr/)£ 11— <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH V SBOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED 4/ 0 (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 7 Title/Company AaO 4f=i Mg Nq Ftp <br /> Print Name 7'. Cy£//C,— Date1rjL111 as <br /> DE,P[ARTMEN- USE _ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 7 D Gh �� 1 l9r�C ✓1 <br /> WORK PLAN DATED: S 7' Zoo <br /> Application Accepted By Date Issued �- Area Ob <br /> Grout Inspection By Date �i`3-C)5 Final Inspection By late <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# ' <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> soi z9-7 <br /> 368 31 � Cmc to-�o sR#�4 vim`? <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_Enccaer6ment.iet OlL <br /> El'D 29-02-001 <br /> 6/22/04 <br />