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'flPquJr� cq man Joaquin County <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 /> �9.%F p42N�P <br /> 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 /> / / J L Assessors <br /> WELL Location 06 glbt,l W�i C IA6V1,n -fT'ross Street A do� �P <br /> SCity' "6� &4j Zip � 2© Parcel# <br /> PROPERTY pt �) <br /> Owner-C4)1 Address 4s�i E/dfl✓ALlC Sf City.9Qt.lcfbiv Zip .SUZ Phone 937^P349 <br /> C-57 Contracto%t35[=l1dt .Dr7AMTp t Addresj 0W&n VC(.P —Cit yt('Or�� Zip"!`2 Lic#7/7940 Phon <br /> Consultant/Sub CntrMtVa,'<. W 8AU Address f�7_5ka 1W City5 Lic#r 90227 Phone#_-1Yk7—)DOG <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> [NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) D DESTRUCTION (choose type below) <br /> D SOIL BORING# D OVER-BORE. DIAMETER <br /> WELL# D PRESSURE GROUT <br /> D*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA2 t, <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS�°� 40 TYPE OF CASING: D STEEL APVC D OTHER: <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL I-L� TREMIE TYPE TO BE USED: D AUGERS a HOSE <br /> D AIR SPARGE/OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED: D Yes �N (NOTF� MAXIMUM FEE-FALL DEPTH IS 30') <br /> D SOIL BORING D HAND AUGER GROUT SPECIFICATIONS Dc1 r [Bv.-t C--�+ <br /> D OTHER:_0 OTHER APPROX.BORING DEPTH BOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSEDfilT/A- (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 /> 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�l /_ >C .� X /L Title/Compan �(n0 <br /> Print Name V \ 1 ` C Date 7113 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,AD RESS: Lf 3�3 -S C O .5 <br /> WORK PLAN DATE,D:�,/� 4jly j)-_5 <br /> /l <br /> Application Accepted By "�' ` ` Date Issued 7 � V S Are <br /> Grout Inspection By 7V Date -7121/65 Final Inspection By 'M, l 0 Date 9 (� <br /> Destruction Inspection ByDate <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 /> 0 2 $ 30 2� `��y 7 65 SR# L !2- <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 />