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� War <br /> COPY <br /> ff+Q San <br /> n Joaquin County I ,Fl v a��l <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95202 MAR 2 1 "%ITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sigov.org IRON MENT HEALIUNIT IV <br /> \�Q.. s..N;� PERMIT/SERVirEs <br /> \trd 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 /> Assessors <br /> WELL Location i7R O VI'A t^wc-ot-a Cross Street Vbth- N4^he�City -'C '2 � Zip9 372 Parcel#'1A�'(1 -03y ^I <br /> PROPERTY <br /> Owners�'Nu-6-4 C-c�+PA�"t Address \14517 Vie vJ..coLo City Mfr-. ip S_S3�7 Phone#ZoS' g3�--Lt6o� <br /> C-57 Contractor V $.-,/ DR•XIX- Address PD QW Lk lr� City i5sGraJ Zip RS6•d I Lic# Phone#`X66-77-�- 4 u <br /> Consultant/Sub Cntr `Y Address City '— Lic# Phone# <br /> GIS Coordinates:X T• <br /> •� « ,Y X121• JJI ,Township S Range U Section :Z L <br /> WORK TO BE PERFORMED: <br /> W WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') g DESTRUCTION (choose type below) ` <br /> 6 0 SOIL BORING# p OVER-BORE. DIAMETER <br /> -1/VELL#_g LS 1po�)Z , 20W 3 19-0151 `'Dr^"A n PRESSURE GROUT j <br /> g'Other ) GROUT SPECIFICATIONS C <br /> COMMENTS: t'1 6 a4!�; LA . tae— z wc.QQS Pi+�-� o <br /> P.DW Z 3 f aAe. ce is"6V L W rls <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 1 / ,_I. <br /> v10NITORING ffHOLLOW STEM DIA.OF BOREHOLEyrC_ 0 MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA: Z•� W ? <br /> a EXTRACTION g AIR HAMMER/DRIVEN CASING THICKNESS SC Fr rt O TYPE OF CASING: g STEEL `ZPVC g OTHER: �( <br /> g VAPOR g MUD ROTARY DEPTH OF GROUT SEAL '" %b TREMIE TYPE TO BE USED: g AUGERS q HOSE <br /> g AIR SPARGE/OZONE g PUSH POINT(GP or CPT)GROUT SEAL PUMPED: #Yes g No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> g SOIL BORING g HAND AUGER GROUT SPECIFICATIONS C,�4 --d T�u + <br /> g OTHER: OTHER APPROX.BORING DEPTH to0-'�S"U�� �S c�1 � ()BOLTED TRAFFIC BOX or -STOVE PIPE <br /> � � (7 CONDUCTOR CASING PROPOSELryexr� (if YES,list specifications in comment section) <br /> COMMENTS: G"-e-L C. cWc (v Cr % os-c Gc PD')- d CDU-S t- <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 /> Court rdinances, R les an egulations, and all applicable California State Laws. <br /> Signed x \ C- Title/Company t^^�(' � )'1'X J�ti F�.+-. �•w <br /> Print Name I )STD^O t.� / F-rlL/i"'^'� x3�Z Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADORE S <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued - Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By D I <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PECODES FEEINFO AMOUNTREMIMITTED CHECK# RECD BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> SR# QS3 <br /> C-57WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />