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roe.• . �o San Joaquin County FILE COPY <br /> Environmental Health DepartmertSITE <br /> �� ' <br /> 600 E. Main Street Stockton, CA 95202-3029;1 �j�, n' _ I _ MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org%eh8`:-" <br /> _ ' UNIT IV <br /> O `Q <br /> Well Permit Application A0 ;C107 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE4S$`t11r{<1 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work desc iliA�'.f;7his appli�etivrh'i5t de in compliance with San <br /> Joaquin County Development Titley,Chapter 9-1115.3/and the Standards of San Joaquin County <br /> .EEnvironmental Heilt 'De46n`'ent. -7 <br /> E 1 d �) 4,rx f. City 1/4 C Zip I S? Parcel#Assessors <br /> �� <br /> WELL Locatio �! ,ya )•,P..✓ Cross Street? c� r� <br /> PROPERTY <br /> Owner( )InA2vn ?6.GtARL Vw 112',ddress /yqqS' AikkSo-X S� City G1Itl` Zip(S� t Phone# <br /> C•57 Contractor(�Ire1'_" U° 4", Address /0&Ve tC City.H✓Tt��`Ziprl°jj Lic# Phone#C�Zs�l3 r�r�0 <br /> L�4' S�e.fSW ` <br /> Consultant/Sub Cntr N -CAMS S Address IC 't om City— j f✓GhG�ic# Phone#(Yf� <br /> GIS Coordinates:X 3743 J ,Y —12-1. 43I ,Township z Range Section ZE5 <br /> WORK TO BE PERFORMED: <br /> p►NEW WELL/BORING (CPT,GEO PROSE, YDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# I f Z 4 „ ryr� 0 OVER-BORE. DIAMETER <br /> 0 WELL# .F PRESSURE GROUT <br /> a*Other ` tt /_GROUT SPECIFICATIONS <br /> COMMENTS: 2 le i Q�Irj 4, ,oae,, <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE, � 0 MULTIPLE CASINGS <br /> 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS N7 TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL T•�>. TREMIE TYPE TO BE USED: 0 AUGERS HOSE <br /> 0 AIR SPARGE/OZONEUSH POINT(GP or CPT)GROUT SEAL PUMPED: gYes a ENo (NOTE: AXIMUM FREE-FALL DEPTiq IS 30') <br /> Q�OIL BORING a HAND AUGER GROUT SPECIFICATIONS _r� <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH �D �k 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED -VO (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 <br /> _Laws. <br /> t <br /> Signed x�&Ile � ��ir� +��.- Title/CompanyC�1C Q 1��" — ,,� � 1j <br /> e ��y t <br /> Print Name ��*-µ'rl, � t•�t_ACiw Irk Dated <br /> — \j — DEPARTMENT USE ONLY <br /> L4-S9 <br /> SITE MAP IN UNIT IV FILE, ADDRESS:_ 50 W- <br /> WORK PLAN DATED: t-vo& g 2 <br /> Application Accepted By Date Issued ` / Area <br /> Grout Inspection By Date Final Inspection By 'we <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 2-q01 :5pj� 8�. ' 035`11 V C4,- T-roilSR# <br /> C-57 WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD 29-02-001 web <br /> 6/22/04 <br />