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San Joaquin County • <br /> a y Environmental Health Department SITE <br /> w: •' 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd NIT IV <br /> rt4 % Well Permit Application 04 DEC 23 arl i2 2$� <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 aqd the Standards of San Joaquin County Environmental Health Department. <br /> 4 "?5'wGlf L-�nL n I Assessor 2 <br /> WELL Location , i ffi�'T Cross Street V W. City YJYI Zip �5�G3 Parcel# 1 [X.u�—13 <br /> PROPERTY-? (` L,,�, I ('� (J ' .I n q q/14 —GZD—GI—►( <br /> Owner fd(4:'CT �K!'�[-' A Address 2J�1 W. Utas i&An S( itlr�kzip SZ03Phone# o`fi 1 IY(o- LZqIo <br /> C-57 Contractor T—::b�_ A ' Address CityZip Uc# 06a9Phone# '1 /� �j <br /> Consultant/Sub Cnh 1=12M 11 a. 'FSR_a„Ciry 0" eA/1n i; Phone# Z't -q 7O <br /> Address L- offf C p <br /> GIS Coordinates:X ,Y ,Township Gfi(tT(G D Range (OL M •D10116 Section <br /> WO K TO BE PERFORMED: &P <br /> EW WELL/BORING (CPT,GE PR BE,HPDR?F� ( �,HAND-AUGER,OTHER') g DESTRUCTION (choose type below) <br /> / OSOIL BORING#�ci� �!J` T DOVER-BORE. DIAMETER <br /> WELL# 0 PRESSURE GROUT <br /> p*Other •. GROUT SPECIFICATIONS <br /> � /. <br /> COMMENTS: �I • ) •4Vtl� 1NtVlar4ndia,_'. tiIS ]'IP�614 9Yailild <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING p HOLLOW STEM DIA.OF BOREHOLE_.' a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: _ <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: p STEEL 0 PVC 0 OTHER: <br /> p VAPOR p MUD ROTARY DEPTH OF GROUT SEAL I Cj TREMIE TYPE TO BE USED: g AUGERS a HOSE <br /> 0 AIR SPARGE/OZONE *USH POINT(GP or CPT)GROUT SEAL PUMPED: g Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> ,SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> g OTHER:_0 OTHER APPROX.BORING DEPTH I p BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (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 I' tion and that the work will be done in accordance with San Joaquin <br /> County rdi nces, Kula d Regul tuns,and all applicable California S ate Laws. Qo <br /> Signed x i Title/Company <br /> Print Name YI JDate <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: /� p V� <br /> Application Accepted By�&I—loa /1 Date Issued (Z(30 Lo Area t <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date I <br /> COMMENTS/CONDITIONS: SIS 0'L /45---ei - <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED I CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 'g_9 n 1 $� `aq �Sh S l N-k- / o� SR# D FD€3o <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 />