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FILE <br /> COPY <br /> + San Joaquin County <br /> Environmental Health Department SITE <br /> < 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: ,vNvw.sjgov.org/ehd UNIT IV <br /> .� Weil Permit Application ON <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 /> Z-'qC I 4. W.1 S v., i va j. W:ISO" d Assessors <br /> WELL Location <br /> (A-4cLu l #1 y�C4SC Cross Street 5ct- t"ne-#� City �� �� Zip YSz��S Parcel# 1/70YOPY <br /> I PROPERTY ���a""`I 2.•.-�✓na�s:.Yc.f/ - <br /> Ownerf},lercr IZFc-f fs4o-k Cc, Address 2 27 N. Cc..�r / f/+ECity Phce i Zip 95CC'� Phone# <br /> C-57 Contractor C rcjq Rrjl,v�q Address q.5-4'y,..,-e- Ra. .1� City 1e-r4."E Zip�'/aS s Lic#�1851(S Phone# q2�' 3� 'S�Po <br /> Consultant/Sub Cntr (0.e v:rr,�w,e� /Address M33 K. Ird Atte _City Pk-N+'x Lic# Phone# 462-72,r d-?-D,Z <br /> GIS Coordinates:X •`($3 Z S-V'f ..y I Z1.2?4 65-LY Township 7 z N _Range E Section 3 e' <br /> WORK TO BE PERFORMED: <br /> "EW WELL/ BORING PT,GEOPF;OBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> R SOIL BORING#BORING PT, <br /> 1)P-9 a OVER-BORE- DIAMETER _ <br /> a WELL#_,,111 w-14 M w /4 C a PRESSURE GROUT <br /> n'Other _ GROUT SPECIFICATIONS____,__-_ <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> $MONITORING a HOLLOW STEM DIA.OF BOREHOLE_ Q MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA: 2- <br /> a <br /> a EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS cf'lS�i _TYPE OF CASING O STEEL J;PVC G OTHER: <br /> p VAPOR p MUD ROTARY DEPTH OF GROUT SEAL-",-- a , TREMIE TYPE TO BE USED: RAUGERS 0 HOSE <br /> a AIR SPARGE/OZONE 'g PUSH POINT(GP or<j�jGROUT SEAL PUMPED: 0 Yesa' 0/No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS IVCm� �'�'-( ) Y., L <br /> o OTHER: fl OTHER APPROX.BORING DEPTH ROLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED ` (if YES,list specifications in comment section) <br /> COMMENTS: al4h[Int[� X211 4r(a�*,rl#"5 r�.,t/ ' j""-e lr2t�tS tSrcE � 5' <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 9 <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 Laws. <br /> Signed x- — � Tifle/Company Amcr-lA &.C.A -gbt'it*Z tJJ {Jtiy�. <br /> Print Name_Rogey= il� �! -'-j Date <br /> -zzTGq t] <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS:_ C -70( Aj• lC/(.L,IrN,- <br /> WORK PLAN DATED: Z°- 3 -Cb <br /> Application Accepted By __ Date Issued Area <br /> tp_ Q Qp <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEEINFO <br /> AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR# <br /> C-577WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc� <br /> EHD 29-02-001 <br /> 6/22/04 <br /> 3 <br />