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San Joaquin County <br /> � ,; � Environmental Health epart enthREVE 7DSITE <br /> ; ( 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209) 468-3449 Fax: (209)468-3433 Web: www.sjgov.org/eiXL — 6 2005 UNIT IV <br /> Well Permit Application EfIPVIRO ENT HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEl?FRM1T/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 Nrgy/_1 <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. tql-1S®-t1(i <br /> Mane 10, Rd. Assessors 19t`plmo-13 PIMW <br /> WELL Location GreWBy Rd, Cross Street MQ^Ihel �Nnv-oP Zip 95330 Parcel# lgt-Abo-1SNtAW-3 <br /> Iqo- 7.(#0- 17 I`1Mvj-L <br /> PROPERTY 1 17 X%7 S. Man}fey �� 1 ClW : <br /> 1-110- 'X1 IJrn ' <br /> Owner 'q'Ctj Pto�erl�e5 Address P•0. 6az 310 City lo ZipIS330 Phonet?J�'i,982'754 <br /> C-57Contractor-�Pe4rvrn I-)-, a�ldnAddress 1346 WC!iwa-fn Dr. City5+ocjjor1 Zip 5 o Lic#S11A6 Phone#(Aol) 611.5-$717. <br /> Consultant/Sub Cntr b 0&o -t'ne Address 1880 N.Teacv Blvd. City ra,c Lic# Phone#(c g $3S-OrodO <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> )(NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# 0 OVER-BORE. DIAMETER <br /> WELL# $ 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: 65-) r14--! !6�o0rrcl-JA 14r t-elan;4,6yi y 1 I wc'I/S -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: Z___ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS O`71, TYPE OF CASING: 0 STEEL $,PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 14 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 glo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Ne-o,1 + <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH I,O ' . 0 BOLTED TRAFFIC BOX or STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: 1r+1L1� de.•1.4;1 * IOC-40MI5 9S a4tCc:bed -,,n WvrK P/ago rn,teol 6v RWQCy3 <br /> (VOTE: 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 OrdinWRuegulations, and all applicable California Statee Laws. <br /> Signedx Title/Company C4,10 t e2eIoAi54 Ew&aj �p'fePrint Namea�.J Date--- <br /> DEPARTMENT ®S <br /> USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: , OGI//�Z�1t r�'/ 2� 5 �`�A / <br /> WORK PLAN DATED: 2 Q <br /> Application Accepted By Date Issued T'O ' 05 Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAG# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <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 />