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San Joaquin County <br /> Eq *,,tmental Health DepartmeL 1.d SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sj*gov.org/ehd UNIT IV <br /> Well Permit Applicatileg AUG I I PM 3: 54 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FRQNi,4QT4IW? I <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install thew C 0 UN 7 Y <br /> 6JN tIyi�¢q ETpi3 ehcatiort is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin CddfitA9partment. <br /> g21 S KJ,I Assessors <br /> WELL Location {{/���� 11SQL� 'IMgg��Cross Street�t +STCity Zip 202. Parcel# <br /> Owner Do Vlo'� Hili Vie)o- . dress-54071E. rgornn{'__ N City L Zip Z/ Phone# �/`1 464-8675 <br /> C-57 Contractor -70.9N/AddressY�/7�) &d 1 City/lab.` i Zip Li 64—PPhone � ,3 <br /> Consultant/Sub Cntr U Address p pi 7 ,Jvlr.4�)�OA City Lic#-Q32L:L7Phone# -/00( <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> XNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> - <br /> 0 WELL# p PRESSURE GROUT <br /> �1*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 tJ I14 TYPE OF CASING: 0 STEEL 0 PVC BOTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL"FAN rY, TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE RUSH POINT(GP or CPT)GROUT SEAL PUMPED: Oyes 0 No (NOTE: MAXIMIJM FREE-FALL DEPTH IS 30') <br /> )OIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Am ucP . ,_.l 60t 1-+-,`,L <br /> 0 THER: 0 OTHER APPROX.BORING DEPTH 1049 ' a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> otic c. CONDUCTOR CASING PROPOSED A)D (if YES, 1st specifications in comment section) <br /> COMMENTS: T R.1 Q�CJ(p Yfy �oryLrr�l' �7I�- �' @-,,, \ <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 /> Countyy Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x_I iz � �...�,....XJl, Title/Company / � <br /> I <br /> Print Name I N1 r, 1 •Q C � Vyt ca C Date I t� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED-: <br /> Application Accepted By - / 7 ✓ e suedZ Ca <br /> Grout Inspection By Date Fi In action By Date Q <br /> Destruction Inspection By Dat <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT��REMITTED [fHECK#;AREC'DI3YFDATE. PERMIT I SERVICE REQUEST# INVOICE <br /> '35k + 131, �� 80� SR# <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorizoti o si96 permit_ Encroachment doc_ <br /> LHD 29-02-001 <br /> 6/22/04 <br />