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y ^' San''Joa urn County <br /> !' FILE C <br /> q Y <br /> Environmental Health DepartmlI I SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> _ (209)468-3449 Fax: (209)468-3433 Web: www.sjgo .org/elid <br /> ,n,R�,. I UNIT IV <br /> Well Permit Application j <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 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Asses;i WELL Location -i �acOn 5 Cross Street City sfdCxFan <br /> Zip 95.1 parcels rs <br /> 4- <br /> PROPE TY ,{ np gtirSdorx sem. sr,3 O <br /> Owner tr kie .J,,r � Address �'�(r , S-treet City 5&C_ Zip �� Phone# 9A, 7 74, 3 <br /> i <br /> C-57 Contractor G C Address City LZip '.� Lic# Phone# <br /> Consultant/Sub Cntr'4co Address'�37 5�1w4+ Cit S'T 4 (oSr0127 4 <br /> City Lic# Phone67 �ad� <br /> I <br /> GIS Coordinates:X Y Township Range 1 Section <br /> ii <br /> WORK TO 8E PERFORMED: <br /> $NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> f�SOIL BORING# OVER-BORE. DIAMETER <br /> n WELL# a PRESSURE GROUT <br /> O'Other i� GROUT SPECIFICATIONS <br /> COMMENTS: <br /> .I k <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS I <br /> MONITORING p HOLLOW STEM DIA.OF BOREHOLE' MULTIPLE CASINGS 10 MULTI-LEVEL WELL CASING DIA: <br /> n EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL a PVC 11 OTHER: <br /> 0 VAPOR n MUD ROTARY 'DEPTH OF GROUT SEAL rt`A TiREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> a AIR SPARGEI OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: n Yes n No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30`) <br /> ttg�SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS I 4 <br /> a OTHER: 11 OTHER APPROX,BORING DEPTHSSG!r i i <br /> a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> f CONDUCTOR CASING PROPOSED Al/� (if YES,list specifications in comment section) I <br /> COMMENTS:_._7 flS& (a_r 6elo,., lav�b,�. o,•F S��#:L TGt<k,_a i� � ---- f <br /> N <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENTIIOR ENCROACHMENT PERMITS. ' <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> f I hereby c that I h pr aced this application and that the work will beldone in accordance with San Joaquin i <br /> County antes, tions,and all applicable California StadeI Laws. C <br /> Signed �t i Title/Company e I + v-0 r G C <br /> r�� r u I p <br /> Print Na e �i <br /> /11 e _ is Date g'`ZS- rr�OtyS� <br /> I <br /> k DEPARTMENT USE ONLY <br /> ' <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ("ZaU l(Ir r <br /> WORK PLAN DATED: O <br /> 3 f <br /> Application Accepted By Date Issued I� JAreaaa <br /> Grout Inspection B Date <br /> p Y Final Inspection By ate <br /> Destruction Inspection By Date f <br /> COMMENTS 1 CONDITIONS: I <br /> 1 <br /> ACCOUNTING ONLY: AID# FAC# I� F <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# R C'D BY DAT <br /> PERMIT 1 SERVICE REQUEST# INVOICE <br /> C-57 WC. -WAIVER__ C-57 Letter of Authorization to sign permitEncroachment doc� <br /> EHD 29-62-001 <br /> 6/22/04 <br /> FILE COPY <br />