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San Joaquin County <br /> Environmental Health Department CellMODIMITIGATION <br /> SITE <br /> 600 E. Main Street, Stockton, CA 95202-3029 41"'11 <br /> (209)468-3449 Fax: (209)468-3433 Web: www.s* fyv,prg/ee 2a� UNIT IV <br /> Well Permit Application �FRi�i;S�dnTH"14 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r'V�CC J <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 /> LL �� Assessors <br /> WELL Location.55IN�(544. kv'4e 33 9�4" Cross Street's City ✓z.txd_l/ Zip IV?5:555 Parcel# 255/eev8 <br /> PROPERTY /— <br /> Owner L4faS� �Ite Tr1G. Address 176 City 1;1511D Zip 93 5 Phone# 26gY35 <br /> C-57 Contractor G!G Drdin Address 160 t<6M Rd. CityRA4. 1u'Z: Zip?*-5 3 Lic#4W65 Phone#_Q23; 58aa <br /> Consultant/Sub Cntr6eSy L LOW!;V// /3 Address '/75/'f >'Yse S�r On CitvJ4.kA J Lic# Phone#510.2-96 2 4C <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> EW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> []ELL# �' 0 PRESSURE GROUT <br /> 'Other I�I^ GROUT SPECIFICATIONS <br /> COMMENTS: !i( d'11 Z ill cu IuoWful/rr/ Welk Hill a �cai ��liS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> l/ <br /> JWONITORING J-HOLLOW STEM DIA.OF BOREHOLE 911 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 56A 40 TYPE OF CASING: 0 STEEL S:PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Z(/' TREMIE TYPE TO BE USED: VUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes ;"o (,NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH YS 0 BOLTED TRAFFIC BOX or',[fsTOVE PIPE <br /> CONDUCTOR CASING PROPOSED ✓U7 (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 Regulations, and all applicable California <br /> ,/State <br /> /Laws. <br /> Signed x Title/Company_: l/ G�s(il <br /> Print Name /Ul /"l(/ 1 Date �/2C/'1;1 <br /> z DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: >� )0 S. 9tv� �? <br /> WORK PLAN DATED: ^ • ZO 7,00.7 <br /> Application Accepted B�y7 Date Issuedeh,-Yo 7 Area <br /> Grout Inspection By �(�.� ��� Date i,�% V f Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: �-U ac =LL <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> Z/01 � ��� �2 1� // � p SR# <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 />