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o c 22 (a��.; ;/� ,�n JoaquinrCounty 10 <br /> FILE COPY <br /> r �EC 1.=': : !i., ironmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 MITIGATION <br /> • DEC �4)21W43449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> C� �P <br /> Fo LNViRUiJ dit:(dT HEALTWell Permit Application <br /> PUi f" i 1'SNOVQF�NDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby mad6 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 <br /> Title,Chapter 9-1115.3 and the Standards of <br /> San Joaquin County Environmental Health Department. <br /> Assesso�2�5/ LfI� /5Q(,!/� 41y *" y tL t.1'4_o zip Parcel#r -28"O-0° <br /> WELL Location T Cross Street _ Cit -o. <br /> PROP <br /> `Owner : l0' 1J1 c.•-ae,IC4�� Address - City Zip Phone# <br /> C-57 ConlractorV'I- bl ,L11^ T Address 100 S 54 ` CityT7td� Zip9SW1 Lic#3?07CM Phone#(a-16)-t+}-Y10U <br /> Consultant/Sub Cntr FM-EC.) 3� ns- Address(,3) CO"^AM''lc'�j Cily�F o Lic# " Phone#/ms\I6)78-6-&8$3 <br /> GIS Coordinates:X -,Y ,Township Range Section <br /> WORK TO BE PERFORMED: - <br /> g NEW WELL I BORING. (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) p DESTRUCTION (choose type below). <br /> -a.SOIL BORING# .. . a OVER-BORE. DIAMETER <br /> [WELL# M W-�D - a PRESSURE GROUT <br /> a*Other. � — GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> XVONITORING XHOLLOW'STEM DIA.OF BOREHOLE-I11_ N MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA: E7 _ <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS S a.NO TYPE OF CASING: 0 STEEL XPVC D OTHER: <br /> U VAPOR - a MUD ROTARY DEPTH OF GROUT SEAL rL�-�• TREMIE TYPE TO BE USED:. 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED:. a Yes Po (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS N� CL-----4� <br /> a OTHER: - Q OTHER APPROX.BORING DEPTH Zt) _�+, a BOLTED TRAFFIC BOX orXSTOVE PIPE <br /> CONDUCTOR CASING PROPOSED - (if YES,list specifications in comment section) <br /> COMMENTS: <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 ap I'cation and that the work will be done in accordance with San Joaquin <br /> County 0 rdin s, nd Ions, and all applicable California State Laws, <br /> Signed Title/CompanySA� teGe' ,GCk/EQ&r=G a-,C_ <br /> Print Name ^t:�.^t-f I G, lJ�rl - Date G 2-NGV•' 0"I - <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: BGlM&10._ db' <br /> WORK PLAN DATED:,— <br /> Application Accepted By Date Issued Z Q Area ICY <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 /> 3UYZ SR# v <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit Encr ent doc e <br /> EHD 29-02-001 - ox <br /> � <br /> 6/22/04 <br />