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/a" San Joaquin County E �LC���1�; <br /> Environmental Health Department : SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 9s�'2'{���i 1 (`0907 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.s FH UNIT IV <br /> Well Permit Application �'E��v�'�/��Rt'ICES <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 /> G�'s r Assessors <br /> WELL Location 24'L N OYkh Su m Cross Street_M�vt-Q-r City o c�acc n Zip `1 S Z c 1 Parcel# %3`l L S G C, <br /> Av-Q-Y�v.s- <br /> PROPERTY <br /> Owner Address 1A.Dv1 City Zip c1 I23Phone# <br /> LiL"(� ti 3�0 \ta-...cJhv �1S 1�ki 'l1 j5�v <br /> C-57 ContractorQc.\i�•�3 Address 11,P ocher Q-.rc,�City c�devc, Zip�c Lic# Phone# (rj1C'j (0�s t-ili'fj <br /> Consultant/Sub Cntr 10.4�o o�� P 1n�o•�� ( <br /> Address � 5 1c .�o City Scxc�v Lic# Phone#``\Ito) <br /> GIS Coordinates:X ,Yt cC <br /> ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> `g SOIL BORING# SC3- ac S 13 t ey'k .� CoV��rt,�pcQ 0 OVER-BORE. DIAMETER <br /> V WELL#_ cx� -(o �� �,�c_Yl„ ria A1) 0 PRESSURE GROUT <br /> 0`Other GROUT SPECIFICATIONS <br /> COMMENTS: _4 <br /> 44 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS � <br /> %MONITORING HOLLOW STEM DIA.OF BOREHOLE `6 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING D���__ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL %'A' TREMIE TYPE TO BE USED: 0 AUGERS ;WHOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 YesNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS_ -k S -1. <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 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 xKX`N C"' Title/Company <br /> Print Name -K <br /> �——��T Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: Z�-{Z S �-{,.�S-{ <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued 1 1 1 'D } Area <br /> Grout Inspection By <A�oer�E Date t L o Final Inspection By ( (��. .�_ Date O <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: Go 5 <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3SO� ��:00 000L3t;$Y�/ I'rr p� SR# G13 5 <br /> C-57_ WC_-WAIVER____ C-57 Letter of Authorization to Sign permit t! Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />