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,�,an Joaquin County SITE <br /> EnvironmentaLHealth Department <br /> z' z CA 95202 MITIGATION <br /> 1 304 East Weber Avenue,3rd Floor, Stockton, ov.org/ehd UNIT IV <br /> (209)468-3449 Fax: (209)468-3433 Web' www-s]g <br /> L1po a`�• Well Permit Application 2005 JUN 20 AM 10 4 <br /> NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DA`T t8SW ()i),F,j C G U 14 T Y <br /> fiance with San <br /> rb1t'N&'S made in comp' nc 12-1 <br /> '- Application is hereby made to San Joaquin County for a permit to construct an install the work de4ibl�dtt�tls�a11 i; <br /> AssessorsL4F' <br /> Joaquin County Development Title,Joaquin <br /> pter 9-1115.3 for <br /> and the Standards of San Joaquin County E1Ai rr!adD&%*N�_.1.� jr M' <br /> L Cita"'' Zip44-Parcel# <br /> WELL Location Crass Street y <br /> '?-Mo a1�.�n�'c�iL�`` r�r� j �t�c�`ta►-tom one# 'LO9�i�br- �7 <br /> PROP F TY �a ,. Address <br /> 1 .= LA- Ind City. Z�P� <br /> Owner �Cavt , f <br /> �t ddressl�- 1 City' 1 ip ? Phone#707^ 7"+" <br /> C-57 Contractod �� <br /> Consultant!Sub Cntr <br /> {,sus Address2-W7� �� r`�`� City . Lic# Phone#!jkt.- � -2-.9 <br /> GIS Coordinates:X <br /> Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL 1 BORING (CPT,GEOPROB HYDROPUNCH, AND-AUGER,OTHER-) p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE.I DIAMETER <br /> a WELL# 0 PRESSURE GROUT <br /> a*Other t t 1 GROUT SPECIFICATIONS <br /> COMMENTS:V-A-QC� t,l <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION n AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL C TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AI PARGEI OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: es a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> QIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH S ©BOLTED TRAFFIC BOX or.;0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if Y list specifications.in com ent section) <br /> COMMENTS: 4S'q — e�Y U22 �..�� cad " '-�S <br /> C:o... ;n,c. ,� �-�.�.L�. ice► ca w.�,�c� -��v..� C�"���-`� � � •,� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I her erti hat I have prepared th application and that the work will be done in accordance with San Joaquin <br /> ' Coun y Or 'n ces, Rul ula i", and all applicable California State Laws. <br /> Signed TitlelCompany , <br /> Print Name i-� UC 1 �le`� L�Cl Date 7 <br /> DEP RTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted� r- 1,1,0,4 Date Issued Imo- I r �" w Area <br /> Grout Inspection By Date ! Final Inspection By Date <br /> Destruction Inspecti0ln By Date <br /> COMMENTS 1 CONDITIONS: (Oc zjl,, r CC S ZOOd <br /> ACCOUNTING ONLY: A'ID# �a'uf ° A �aC p✓� ie� �( <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY ?/AjE PERMIT IS ERVICE REQUEST# INVOICE <br /> L_71 SR# 't -�4 T?-9.-3 t <br /> C-57_ WC---WAIVER- C-57 letter of Authorization to On mi Encroachment dot_ <br /> EHD 29-02-001 <br /> 6/22104 ✓ <br />