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,p San Joaquin ounty <br /> `a Environmental Heal i Department <br /> 304 East Weber Avenue, 3rd Flo, <br /> , Stockton, CA 95202 __ SITE <br /> MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sigov.org/ehd <br /> UNIT IV <br /> qx, O Well Permit Ap <br /> ication <br /> �r <br /> NON-REFUNDABLE PERMIT EXPIRES 1 EAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andh install the work described. This application is madelin compliance with San <br /> Joaquin County Dev I pment Title,Chapter 9-1115.3 and the Standards of San aquin County Environmental Health Department. <br /> WELL Locatio` t � � [1�� Cross Streec Assessors <br /> PROPERTY J% UW" City riyZ- t 7 Zip Parcel# <br /> Owner_ �tA r S AddressS / <br /> /!2!� <br /> Cit Y p4 Zip�4 Phone# <br /> C-57 Contractor_ Address Ae �77 q <br /> ,t City '✓r�/ Zip6tLi �TG one#.jL) 0( �/ <br /> Consultant/Sub Cntr_6�/�C�'�k66Addres , /�- <br /> lel//City_ Lic# Phone#,Z,)> gyP13`J1— <br /> GIS Coordinates:X ,Y ,Townshi � <br /> p Range Section <br /> WORK TO BE PERFO GF <br /> 1XV WELL/ ORIN (CPT, OP OB HYDROPUNCW,HAND-A GER,OTHER-) 0 DESTRUCTION <br /> SOIL BORING# r�7 (choose type below) <br /> []WELL# 0 OVER-BORE. DIAMETER <br /> []*Other []PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPEC I:ICATIONS <br /> MONITORING []HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS []MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC <br /> []VAPOR []MUD ROTARY DEPTH OF GROUT SE C j r TREMIE TYPE TO BE USED: 0 OTHER: <br /> []AIR SPARGE/OZONE []PUSH POINT(GP or CPT)GROUT SEAL PUMPED; Yes []AUGERS OSE <br /> []SOIL BORING [] 0 No (NOTE: MAXIMUM FREE-FALL DEPT IS 30') <br /> []HAND AUGER GROUT SPECIFICATIO' � <br /> []OTHER: T�,l"OTHER t�V'^oC APPROX.BORING DEP r7"Z <br /> 0 BOLTED TRAFFIC BOX or 0 STAVE PIPE <br /> COMMENTS: CONDUCTOR CASING OPOSED (if YES,list specifications in comment section) <br /> I <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESSREEMENT OR ENMPERMITS. <br /> 48 WORKING HOURS NOTICE R CROACHENTUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that t e work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x <br /> Title �ompan y Cf }t'r�/� �.. <br /> Print Name P /y <br /> rG Date_ f�zZ�G� <br /> DEPARTMENT �JSE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: L Ll-�-3 t <br /> WORK PLAN DATED: ) p <br /> Application Accepted By Date Issued �7/�`f(/ Z <br /> (-rout Inspection By (A� 7 Area <br /> ^^��c� Date �1 `I al Inspection By1 v <br /> ostruction Inspection By Date _ Date <br /> COMMENTS/CONDITIONS: �I <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# <br /> REC' IIBY DATE <br /> �.� & � PERMIT/SERVICE REQUEST# INVOICE <br /> ' c� �� 13d s.�� '�� S R# <br /> 5 a 1I y <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorizatio to sign permitEncroachment doc <br /> EI ID 29-02-001 _ <br /> 6/22/04 <br />