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*zvv <br /> San Joaquin County <br /> Env&mental Health Department* SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> Well Permit Application <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 /> 04-1 R ANT- <br /> WELAssessors FAST of <br /> L Location QST of Io15 W/Ilan W�>/ Cross Street MArKt I S}; City SfD_ CKJ'o ryt Zip `52P5 Parcel# ISI^ 25 - 07 <br /> PROPERTY A'i'": RF/b C/�.ip�,jl -- <br /> C'Ty 345 tv,rzLDo,4AoQ}ci yszPz_ Czs4) <br /> Owner 1 ocf 5ToC1STa�pddress 11 ty5i lfro.4 Zip Phone# `I3"7 1634 <br /> C-57 Contractor f£ Addresscr5p r7Av„p pt,pD CityNAf1-1.P Zip`+Y 5 Lic#6RV67!Dhone# LS / <br /> Op <br /> Consultant/Sub Cntr AGF -Address 9'3-7 StlAly R0, CityS7_0(6To&Lic# SOz2 7 Phone*�f Y �-/o0� <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED, <br /> NEW WELL/BORING CP GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) D DESTRUCTION (choose type below) <br /> SOIL BORING# C C '(=�ICP -'7 0 OVER-BORE. DIAMETER <br /> LL# 0 PRESSURE GROUT <br /> 0' GROUT SPECIFICATIONS <br /> COMMENTSS:: SE fl GROUT <br /> 1'IHN hAT£n 11 �OS aevisvll L L,rir TAN OA7eA os�Z31/J� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING D HOLLOW STEM DIA. OF BOREHOLE ! D MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS N1.4 TYPE OF CASING: 0 STEEL 0 PVC D OTHER: Nlg <br /> 0 VAPOR D MUD ROTARY DEPTH OF GROUT SEAL 6 `J r TREMIE TYPE TO BE USED: D AUGERS _Ivo E <br /> IR SPARGE/OZONE PUSH POINT(GP o CP ROUT SEAL PUMPED: `(Y9'S D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING DHAND AUGER GROUT SPECIFICATIONS_ orrlAHO T�f1�, <br /> D OTHER:_D OTHER APPROX.BORING DEPTH I bn r 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED_(If YES, list specifications in comment section) <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 Sate Laws. <br /> Signed x TTitle/CompanyW4111' o <br /> Print Name_ // PAI-/(/ V e,��/�)/� Date Z3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: /0-( 5-. &0/t1 //J$/OS 4 lupA 6 �23� <br /> WORK PLAN DATED: II <br /> Application Accepted By Date Issued (64Z 71d(, Area /f✓fL <br /> Grout Inspection By /YG�/ Date 'i' 2�-L o5- Final Inspection By a/G l� Date `/�2¢/O� <br /> incl <br /> Destruction Inspection By Date ' <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# F <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D/�BY DATE r PERMIT I SERVICE REQUEST# INVOICE <br /> 35 1 7? 2 9oW z"(0 7CN�r4p 2(G 6 SR# p(0`f7219 <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 />