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• , c <br /> San Joaquin County� FILE COPY'� ��/ <br /> y > Environmental Health Department jb'V 2 SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 91 �?105MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: wwwsjgov.or SEN) UNIT IV <br /> 4. Well Permit ApplicationR�!�) S ,RI»��ALTti <br /> S <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 /> Jo quin Co my Development Ti e,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> IN N1 01 sou 1 11 Assessors <br /> WELL Location 41 Arr�or}Cross Street iawon o City p 9 G3Warcel# NA <br /> PROPERTY ! !� <br /> Owner Cr'f!=N( of M-ton�ecc Address 1001 W-CX-Aftr S�1.City t-Var,,lnke-_ � Zip O5311Phone4 239' x'433 <br /> C-57 Contractor l7creo�r 1� `Address95D qow, _Rcl City 1 ww \t\-�LiI,5 1% Lic# AV-5 Phone#q� -3i3^5$00 <br /> Consultant/Sub Cntr Conder C�.r'� -\ Address3 ax 3805 City JOAITna- Lic# Phone# S2,7_-07341 <br /> GIS Coordinates:X 63420 S C ,Y 210$'100 Township ZS _Range 6 SectionI _*Pns�E70 <br /> UT K <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# O OVER-BORE, DIAMETER <br /> ALWELL# 9 aPRESSURE GROUT <br /> 0.Other w /� [ GROUT SPECIFICATIONS <br /> COMMENTS: MW I N fy SIDEI.J/ y'/ I W 1 a l s• Art RPD9 - IN <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLEy __ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSS TYPE OF CASING: 0 STEEL XPVC p OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL rJ 1 D TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS tleo k c.crYv Act <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTHZD T^ 30 0 BOLTED TRAFFIC BOX or STOVE PIPE <br /> (/ �i ++ ,,.. S.`D�ICTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: � aw'31N �+-� T <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 Ordinan sIR I ddations Ind all applicable California State Laws.. <br /> Signedx Title/Compan (,OnJOr r—qYf�( /PCh/t0%g1N1 <br /> ♦ <br /> Print Name Dale <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: Z`�SD W• YOSEY�+-tTE 1�P /wtclq (LIQUGX <br /> WORK PLAN DATED: 2-(D `I 111f 2 O$ /- <br /> Application Accepted By Date Issued ( � I T Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# I F <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> SIR 3 D <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD 29-02-001 , - <br /> 6/22/04 /+ h <br /> A I--_ . I1� - n_n <br />