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-San Joaquin County <br />Envirlimental Health Department <br />600 E. Main Street, Stockton, CA 95202-3029 <br />SITE <br />MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehdUL b 1 2607 UNIT IV <br />GINALWell Permit Application EINVIRONNILDN HL.r;Li;, <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ERMIT,/SERVICES <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 />f �REMo��t S7 Assessors <br />WELL Location �T�O .FRe,��,�}- Ste Cross Street z�l� Sl-, City < rTOLXT""j Zip I��I� Parcel# 4333046 <br />PROPERTY �' ))1 <br />Owner )LOA � Amm j � j�wq f Address y�AO � � FRc�.�nn:�} 511, Citys JGt IGTbrI Zip 2S. I Phone#C'L`Ji�`L _C 75 <br />C-57 Contractor A'� - , Address ',5, % S 44t� ° city IC r- Zips l Lic# c;tl 7Phonek'�'OYL <br />Consultant / Sub Cntr e l , C;. i . Address %7 3'2 Si A 01 A2�, City: J c (--, Lic#4 Z 7 Phone# �Z'30 y %' ��%� <br />GIS Coordinates: X Y <br />Township Range Section <br />PE CODES <br />WORK TO BE PERFORMED: _ <br />AMOUNT REMITTED <br />CHECK # <br />9 -NEW WELL / BORING (CPT, EOPROB , <br />HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />- <br />d SOIL BORING # 3 I <br />0 OVER -BORE. DIAMETER <br />;2 85 <br />0 WELL # <br />0 PRESSURE GROUT <br />cam} <br />0 *Other <br />GROUT SPECIFICATIONS <br />COMMENTS: SE /i'C.,, S� <br />I <br />�o FiS VR�°=.r nv.-S� �c{;'31N �'� V�:� P1:4NV `Z6 -'1'417 Zx <br />1, <br />TYPE OF WELL INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />0 <br />0 MONITORING 0 HOLLOW STEM <br />DIA. OF BOREHOLE- 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: All Q <br />0 VAPOR 0 MUD ROTARY <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS A HOSE <br />0 AIR SPARGE/ OZONE A PUSH POINT (GO or CPT)GROUT SEAL PUMPED: 0 Yes '0 No (NOTE_: MAXIMUM FREE -FALL DEPTH IS 30') <br />1] SOIL BORING 0 HAND AUGER <br />GROUT SPECIFICATIONS TO A.) TQC- -LL— <br />0 OTHER: 0 OTHER <br />APPROX. BORING DEPTH > 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />� <br />COMMENTS:� ` � 1v i) —<�� <br />r <br />�J� , < � 1 i 1v �/� W�:iy /� � ? R itl14JQ; -I Z� _ <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 State Laws. <br />Signed x_ -Z. .�- Title/Company O t' <br />Print Name ".1 \ Date- ( '7/-%j k <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATI <br />DEPARTMENT USE ONLY <br />Application Accepted By r1 e Uate Issued a / G / V ( Area i r .� -t <br />Grout Inspection By Ji Date 0'7Final Inspection By Vj'Zt r ,J, nlc lir/fries. Date S -/ `Y - D7 <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: d �/ d o [' I ryt P_,yt D 2 5a i t bo r, a4 S .-F-13 and P-14 -{n >^ S o, i as s 06 I leeorn <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />3503 <br />;2 85 <br />3%'x.00 <br />24,020 <br />�-e4??_ <br />c.7 <br />SR# �0$l4q� <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc <br />EHD 29-02-001web <br />6/22/04 <br />