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o�q San Joaquin County <br /> Q �y� Envirdonental Health Department IR SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <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 /> Cf+y RiGHT- flF-�wA./ • wi0Q" w,Ay £ Assessors 1 N*l OF <br /> WELL Location EAST eF to l S. W 1 bDn W�Cross Street MAf Kk L S+: City 5 For,KTn+y Zip 952x5 Parcel# ifl^ 25'1^ O-/ <br /> PROPERTY ATTti; RF/O ctvvhe%l 5}. 9510?— QL s4) G <br /> Owner C;T-y o F I oCKT%,Address 395 N,FL D DAA0 P City­S I aK T0,4 Zip Phone# '137-1G 34 I <br /> C-57 Contractor V re Address 955 1`44yye QoA D City NArb�zZip`tY55$Lic#65lLyn7Phone# ZS '$/ ^ oP <br /> Consultant/Sub Cntr AGF Address 837 S8Aty 80. City ST9CK70NLic#j25O7-2 7 Phonekt. y` <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED; <br /> NEW WELL/BORING 'P ,GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> "'SOIL BORING# C 4 G T-t./CP l.'I 0 OVER-BORE. DIAMETER <br /> WELL# 0 PRESSURE GROUT <br /> 0*Other _ GROUT SPECIFICATIONS <br /> COMMENTS: SF£fd ?Praveb W, Af PIAry 4AT£a IUj X 05 t & ,sen kJPrK ?/J J 4A-rQD 05/2310' <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE ULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:_�/ <br /> /- q 0 M <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NIA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL / fa `J r TREMIE TYPE TO BE USED: 0 AUGERS AROSE <br /> 0 AIR SPARGE/OZONE PUSH POINT(GP or CPT)3ROUT SEAL PUMPED: `B1' s 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS s r I,IA.0 Tom£. TL <br /> 0 OTHER:_0 OTHER APPROX. BORING DEPTH I Ion r 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED nl.IA (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 S ate Laws. <br /> Signed x 4h ( �t Title/Company <? _ . �• <br /> Print Name /1 ✓� `V � �/o/o, Date Z3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: Cd,If&L ( _/�P �� I s as e <br /> WORK PLAN DATED: J <br /> Application Accepted By l✓�///, Date Issued __(bArea <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# F <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'DBY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR# 00J2219 <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc <br /> HHD 29-02-001 <br /> 6/22/04 <br />