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tier San Joaquin County <br /> Environmental Health Department r I L LTQ u 1 <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 /> °' rFOR P Well Permit Application r <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED -7 t <br /> � t -ragqool <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 comp is �atith an <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department / `7 UUUU / <br /> A IPI ne-Avg•. 5t ac K Fo a 952011 Asesso Assessors/A tr- C) . <br /> WELL Location Z 8bZ wo5f L4✓l4 Cross Street City Z4 <br /> PROPERTY MI II Crcc lit.. /3!3 U. leobmhooa0 5f 044or7 9'540 (Z- aa)y 51 ' 35-SS <br /> Owner Lglaras,I.L L Address 6*4;lG A - 9 City Zip Phone# <br /> /0e/ E,55CX sV4 C Gnd �y 363Bn ? 3-7- (-/57SC-57 Contractor Pe LIS lO h Address { y- ipic# <br /> dessS ` � <br /> Consultant/Sub Cntr6umaIrly Ami{ 06 '1City`eUc# <br /> MIA Phorle#crr6, 6-3(6' 3a00 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/ BORING EQPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# _b Y%N �S 0YI �la2 e/ D OVER-BORE. DIAMETER <br /> 0 WELL# DGROUT SPEC FLOAT UT <br /> ONS )Vea.4 C et lmd fo''3' <br /> 0 Other � �1 <br /> COMMENTS:Ba/'in l gill � cLd Lrgmc4N Ar SOi I•, scid yaig C a4a La4mdWa'lGY' Sur+rvb eller <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING a HOLLOW STEM DIA.OF BOREHOLEL" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL D PVC D OTHER: <br /> 0 VAPOR D MUD ROTARY DEPTH OF GROUT SEAL4 %-3��'S TREMIE TYPE TO BE USED: BADGERS <MD <br /> D AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> D SOIL BORING D HAND AUGER `�GROUT SPECIFICATION <br /> OS <br /> 0 OTHER: 3 / Ccf' -IkAPPROX.BORING DEPTT* Se+Jx-4et.J 0 BOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (it YES,list specifications in comment section) <br /> COMMENTS: ')E 50/l��SO;I yogrr — 15-). a cJ — 5 0, - <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 x /, \_� Title/Company t1)•fOY'ri� 2 � / -O "� <br /> Print Name V L�/ �k�- Date U/ass <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FI ��E,11AD RESS: B U ) <br /> WORK PLAN DATE- <br /> /:�t "F9 5 '» 0 <br /> Application Accepted By 4�iv�.'s�- ��-7�^-� Date Issued o Area L <br /> Grout Inspection By "`CCC'-- .. .0 Date°� 7�r 1 Final Inspection By <br /> Date --i" d <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 /> 1-Ilk A fl, \ u-I SR# a�S on6� <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 />