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COPY <br /> San Joaquin County I �� Ef��ILE <br /> � <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 MAY '/J'' 2 200MITIGATION <br /> � (209)468-3449 Fax:(209)468-3433 Web:www.sjgov.or 0'ARQ±Vlt4FNiHEraLTPNIT IV <br /> Well Permit Application PERI+!-f,ISERtf <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED O "��^'w <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made i///compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> y y.;Assessors Gln (LOQ / <br /> WELL Location Ibot0b W- Sr�L�Jkk-- Q-<A Cro�ss�Stl�r�eye�t' Q�-�kr�..�'-�SCit Tf4.c-.-t zip 4 ' 7 ) Parcel# <br /> PROPERTY 1-31I 0&4 ` <br /> Owner S�. c.-., , Iv.a-- Address55t% $�-e.-a_t'�i�2 'ReS.CityQLc-.s--ton Zip"Phoogqne,,#pp525-'-17C- 3Z-Z-`-1 <br /> C-57 Contractor V 11,W D .�ri11kAddress �D �� City a.ICJ; Zip qSw I Lid9i^'r6 Phone* 36�k <br /> Consultant/Sub Cntr — Address — City___= Lich! — Phone# -- <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> XNEW WELL/BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 3 0 SOIL BORING# q 0 0 OVER-BORE. DIAMETER <br /> SWELL#LJC­-,q WG?D1aPRESSURE GROUT <br /> `Other GROUT SPECIFICATIONS <br /> COMMENTS: — <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 'MONITORING -)ff HOLLOW STEM DIA.OF BOREHOLE j•• D MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS Q,411 Ko TYPE OF CASING: D STEEL 'g PVC g OTHER: <br /> D VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL —90 TREMIE TYPE TO BE USED: ffi1UGERS D HOSE <br /> D AIR SPARGE/OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED: )%Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> D SOIL BORING D HAND AUGER GROUT SPECIFICATIONS f`-k—+-C�+ <br /> D OTHER:_0 OTHER APPROX.BORING DEPTH — 15-0 IBP30LTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED N O (if YES,list specifications in comment section) <br /> COMMENTS: 3 �CRQ-S c s crv. S' '^J`—i Pte' S�-r <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, Ru s and Regulations, and all applicable California State Laws. <br /> Signed x t `�—"`— �'��--� Title/Company,r-�y, jan�Fnf <br /> Print Name�- 'S L[' (Lo— Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 1T/pJo <br /> WORK PLAN DATED: Q <br /> Application Accepted By Date Issued Z� ' Area <br /> Grout Inspection By Date Final Inspection By - <br /> Destruction Inspection ByEl Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAG# <br /> PECODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 7yJ �9,� L S yzog SR#MO <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 />