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San Joaquin CountyRV <br /> Environmental Health Department S SITE <br /> 600 E.Main Street, Stockton, CA 95202-3029 , T 7 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/eh�du 2 ! c��/ UNIT IV <br /> Well Permit Application ENVIRONl0;E�NT HEPI Tj <br /> PF-R11AiT/SERVICES <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 71� A5 331 ., Cross Street��( City ►�Gyxfc�/5 Zip 1V95�f Parcel# <br /> PROPERTY j <br /> Owner ( igyt* �169 3;1G. Address PC 11LF City 6;6,ft0 Zip 93?15 Phone# 261-935•�5�1� <br /> C-57 Contractor Dr,llin p Address_ 160 h6z kd. CityMwifas-L' Zipf*no Lic# 657 Phone# ?23:313'S�� <br /> Consultant/Sub Cntr G�esynG LON541 Address tla 8 ,�7 s-k4to City Qat A-J, Lic# Phone#.510.2$5.2IcP <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') DESTRUCTION (choose type-below) <br /> 0 SOIL BORING# ER-BORE. DIAMETER � <br /> 0 WELL# /5[fZRESSURE GROUT <br /> 0.Other / / GROUT SPECIFICATIONS <br /> COMMENTS: cJ vc l�YL Ot - 3/,{�hf�f/fimiACi G'ell <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> IQONITORING �1-IOLLOW STEM DIA.OF BOREHOLE t( 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL ` -PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes o (NOT MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS T11t- <br /> 0 OTHER: fl OTHER APPROX.BORING DEPTH!�(j 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: wz C� - g 7/w- W <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCRO CHMENT 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 Law/s. <br /> Signed x Ttle/Company <br /> Print Name N � ,11 Q-' ^i 1 Date 0/0 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS:_��-/DU <; • / Uv <br /> WORK PLAN DATED: u,� l)1 f p <br /> Application Accepted By Date Issued U/�Z Z( Area / <br /> Grout Inspection By ,{ _� Date > f Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: /Z.G✓Q S <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> e7q 02- bD" CSO 2-2- t)7 S R -/ -7 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001web <br /> 6/22/04 <br />