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,anrJoaquin County nn �p <br /> Environmental Health Departme�iAE0 �/ E D SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> ' (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.or0Affi 2 ry 2005 UNIT IV <br /> Rai <br /> Well Permit Application ENVIRONMENT HEALTH <br /> PERP01T;ISE?VICES <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. I -0?O-Z <br /> b 1 L <br /> WELL Location ; 3 lRles+ - Cross Street t�City ,5-Lor-k-4n Zip 15-2- <br /> el# S <br /> PROPERTY -r� O <br /> Owner �R✓I�yl_ IhO r✓It�S Address 1919 G,rz�nd Cann( City ,s'%oc k,an Zip /����``Phone# Z09-95S-zv�Z <br /> C-57 Contractor EN roll Address 9C"Sox-�Qj �I��7 IIP Zip sgkjck7vpz Phone# 54-1.-. - -ZC, <br /> Consultant/Sub Cntr �c n U7� Address (`o (:f;NX�ity �CaS�/t�LidF �� Phone# 9lir-��-� Op <br /> 3�U �� h51 ice.cs5 u ' w pl5,f, N <br /> GIS Coordinates:X 6-Z Z"Y )Zl )L G /, Z ,Townsip 2.N Range Section 's <br /> WORK TO BE PERFORME <br /> JrNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 3rSOIL BORING# :B- ) •-Phre:aEA a 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0`Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS n /ti TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL r 4 TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br /> 0 AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: g Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ASOIL BORING 0HAND AUGER GROUT SPECIFICATIONS sO' I lv l^R's,S�,fi-�+-<T�%� S✓r�wre suI' Ic'enurDf <br /> a <br /> 0 OTHER: fl OTHER APPROX.BORING DEPTH I'�; Y' 0 BOLTED TRAF IF C BOX or 0 STOVE PIPE <br /> J <br /> CONDUCTOR CASING PROPOSED rl O (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 /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances Ru stand Re u tions arttlaftappiieable California IStat�eLaws..) <br /> Signed x1-�' n / Title/Company -S?e,Tn <br /> (_,d�')S✓/T1A/o'I /�-+ ^ �/O✓� <br /> Print me U -kin t'C-/ �d�G�r' Date �ll7/GS �Y ,�- <br /> DEPARTMENT USE ONLY f� <br /> SITE MAP IN UNIT IV FILE, ADDRESS: Z3 a S LJ e� + La ` l tl" ) <br /> WORK PLAN DATED: -t ////r�/� ".� <br /> Application Accepted By _Date Issued S/�OLIPLETEArea L/ <br /> Grout Inspection By­ Date 742,81,25- Final Inspection By_ lil Dater ���k p S� <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQU IN I <br /> 7-016 I -*q or, 3 z 3`o - - cd SR# Li 2,15 Z <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 />