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ra0 OSan Joaquin County • COPY <br /> aEnvironmental Health Department n §ITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 W L� ���TION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> FORK` F� Well Permit Application MAY 2 0 2 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED EfJVIRONIOEW FIEALTHpFR�;I 7�c�p��� <br /> Application made to San Joaquin County for a permit to construct and/or install the work described. This#p(�IIC9iIWNiaWR6r geenplian with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> �LAssessors <br /> WELLLocatlor 28305 5• �CrossStreeiV/4 /?D/O _City ip9 '7 7 Parcel# 951 3Zo/o <br /> PROPERTY LIALLCOD"-ZO9 T.LUS p r/ <br /> Owner iW`�� L/IU-SI LLC-- Address7700C&L.L.&G� "(a-kJ CitySTkOC-Y�r�FA.i%i:ipSSRl-bPhone#A 636• ` o0 <br /> C-57 Contractor V 2LJ OEtLLt K)r_ Address P�- QOx c,'70 -. City 9' `j36160c-> <br /> Consultant/Sub Cnlr IJ 1 W Address — City '-' Lic# — Phone# <br /> GIS Coordinates: b' 7 �R7.$ Township Range Section y <br /> WORK TO BE PERFORMED: <br /> 3NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUG OTHER") p DESTRUCTION (choose type below) <br /> a SOIL BORING# a OVER-BORE. DIAMETER <br /> *WELL#mw-Sa , / p PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: 1 hvr 2- o fic.P4fcc� I w�z0 e- <cdcO% l -9 fo /'n1/G{Ps 1 is /e✓ fv Zc.'.a Cor-✓e(l <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 111` <br /> ,MONITORING 'HOLLOW STEM DIA.OF BOREHOLE" a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: __ <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS S t,1-t `CO TYPE OF CASING: a STEEL JOVC a OTHER: G <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL ^ N5S TREMIE TYPE TO BE USED: ()AUGERS HOSE <br /> g AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: $$Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) N <br /> a SOIL BORING n HAND AUGER GROUT SPECIFICATIONS (JGA T <br /> a OTHER:_0 OTHER APPROX.BORING DEPTH "'6�' a BOLTED TRAFFIC BOX or OSTOVE PIPE <br /> CONDUCTOR CASING PROPOSED NI 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 /> 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 <br /> Regulations, and all applicable California State Laws. <br /> Signed' -z --�� c-�— Title/Company_Eyr'v, <br /> Print Name C7. �/.>rs LE,I/L71� Zo9-3Z/- -1-0.79 ) Date oS- 741-- /O �S <br /> DEPARTMENT USE ONLY Z9.ia S A <br /> SITE MAP IN UNIT IV FILE, ADDR SS: 17q5o tQ, u Colo <br /> WORK PLAN DATED: Z01 <br /> Application Accepted By Date Issued U Area <br /> Grout Inspection By D (n U Final Inspection By Date VIM <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 4.0 520•/6 sR# <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_ a€ar a# docs <br /> EHD 29-02-001 QQr„_D_on... V <br /> 6/22/04 <br />