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oRO U IN San Joaquin County <br /> z = �\ 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 /> ac,�pg 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 /> �7 n f n " Assessors G <br /> WELL Location J 2—S7 Cross Street t>/��^^a', City�'o I 1 SZ3 f Parcel# <br /> PROPE Y srG -5-23 <br /> -2 3'7 <br /> Owner bC� t _7 Z ul1�� �eCityLG ( ( czipAddress / Ph <br /> one#j!4 7 Sd 3 <br /> V"� Vi/ PG L}GY t�lCc Cit ~S 95Cc41 <br /> C-57 Contractor Address y Zip Lic# 72C9Gilhone# ��tr' -777- L//66; <br /> Consultant/Sub Cntr'5F C Address City Lic# 6r Phone# <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> SNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> RWELL# LINW< f A-W-I //K qJ-7- �IX w3 y TPS�-q 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS tl <br /> MONITORING 11HOLLOW STEM DIA.OF BOREHOLE_LQ_�/0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:------ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 9C �/G TYPE OF CASING: 0 STEEL VC OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL IS TREMIE TYPE TO BE USED: AUGERSiOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: aye f1 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS I , "9 <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH I�1 OLTED TRAFFIC BOX or TOVE PIPE <br /> rI <br /> CONDUCTOR CASING PROPOSED Ln (if YES,list specifications in comment section) <br /> COMMENTS: -7- �� I7S w, l a 0 . 0!-G <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT 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 Or nces, Rules and eg lations, and all applicable California State Laws. <br /> j' s <br /> Signed x Title/Company V 'l <br /> Print Name � Af� <br /> Date goo <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED:I o_ <br /> Application Accepted By 1 1 �^+�"� Date Issued �/ Area �OVPsI� <br /> Grout Inspection By Date Final Inspection By Date gPN s.TN� �MENT <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS e- ✓P2.&J '- C--(� <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST EINVOICE <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 />