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i4 87057. Gob <br /> UI tan Joaquin County ' <br /> >p ep <br /> a Environmental Health Department SITE <br /> < 600 E. Main Street, Stockton, CA 95202-3029 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 9-11 3 and the Standards of San Joaquin . my Environmental Health Department. (��y <br /> ssesso <br /> WELL Location _ ' /. Cross Stree rt Zi Parcel#(��/ <br /> PR <br /> OP <br /> Owner N d Addres�x S L_ _/rity Zip -CPh�opned <br /> C-57 Contracto rn ddres /A'. City ZiQ�Lic# O p o ,J� <br /> Consultant/Sub Cntr Atldres i ityic# Phone# '7 6 '� '7C7 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> WELL# I 0 PRESSURE GROUT <br /> 0`Other GROUT SPECIFICATIONS <br /> COMMENTS: _ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS / 11 <br /> 0 MONITORING $'l-IOLLOW STEM DIA.OF BOREHOLEJZ!� n MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS 3 b <br /> It TYPE OF CASING: 0 STEEL kPVC 0 OTHER: <br /> n VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Cor TREMIE TYPE TO BE USED: 'AUGERS 0 HOSE <br /> p AIR SPARGE)OZONE n PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> u. <br /> n SOIL BORING n HAND AUGER GROUT SPECIFICATIONS (>rc�" G,rMwW lLL <br /> n OTHER: D OTHER APPROX.BORING DEPTH O BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: pr_ y�yL5xvt -o ^I� C,�n, •,�-� S L,M-eve t�rn C'Ta" r 1 — SL�•r'��'u <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ord, ances ules an tions, and all applicable California State Laws. <br /> Signed x Title/Company <br /> Print Name ✓ ate <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: (zl sZ� Ft e�I rMr�✓ rLotr l_ <br /> WORK PLAN DATED: 1 J a <br /> Application Accepted By !-r`^4 v Date Issued Ti '� Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> I'Lol fjk.00 gq.aJ '� 5�< tl� SR#;110 l <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permitZ Encroachment doc_ <br /> EHD 29-02-00lweb <br /> 6/22/04 <br />