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P Of <br /> On Joaquin coufity • FILE COP Y <br /> O ••C <br /> ay' p°yam <br /> Environmental HealthDepartment po sITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 ° °L5 %'~MITIIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehdNOV 2 4 ZHNIT IV <br /> n• r <br /> Fo " _ Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMEN 1 IjLAi ;i <br /> PERMIT!Sg',V C Fe <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install the work described. This application is m e i L pliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. 'j ks^A?N <br /> p Assessors p L. <br /> WELL Locatior//lE(A� W ross Street (- An!X City` / Zip Parcel# �/�—Z60—) 1 <br /> .._.. PRQPERTY-. '��J.Bort/4skl CityS[.AR LLZ� ?6 hone# B 99/- 3 <br /> Owners Gr•.)f+4.tiCA_ Address <br /> M ' Address f 00$' Gily2sla. .,_zip tc#iZo9dti Phone 41b 'i IQ0 <br /> C-57 Contraclory f W WILM%!, <br /> Consultant/Sub Cntrz" — F—n aC. Address ('31 i"_V M.,,, � City�Dw -,�i��Lic# Phone 9!6 4—O'S <br /> '.CIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED; <br /> ANEW WELL I ;^� <br /> BO "— PROBE,HYDROPUNCH,HAND-AUGER,OTHER') a DESTRUCTION (choose type below) <br /> a SOIL B ING# \ a OVER-BORE. DIAMETER <br /> WEL - W—N GPRESSURE GROUT <br /> ROUT SPECFCATONS <br /> [I*Oth r <br /> COMMENTS: - � <br /> TYPE OF WELL INSTALLATION TYPECONSTRUCTION SPECIFICATIONS <br /> ONITORING HOLLOW STEM DIA.OF BOREHOLE__ a MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS sr VO TYPE OF CASING: a STEEL )(PVC 0 OTHER: <br /> L <br /> a VAPOR �[]MUD ROTARY DEPTH OF GROUT SEATREMIE TYPE TO BE USED: O AUGERS a HOSE <br /> .[]AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes XNo !NOTE: IMUM FREE-FALL DEPTH 1S 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS N64 <br /> a OTHER: a OTHER APPROX.BORING DEPTH ZU —t- <br /> . a BOLTED TRAFFIC BOX or'STOVE 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 /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin_ <br /> County rdi a and Regula ' and all applicable California State Laws.r� � <br /> ,� Ge, Ct <br /> Signed x Title/Company c/ <br /> Print Name `q'^`Q—S� �-"� `� Date <br /> 72 Nom- 0L1 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: tf <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued Are _ <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Dale <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> A411,90 1 //-3a SR# DD-1V t <br /> C-5 — WC=WAIVER_ C-57 Letter of Authorization to sign permit ✓Enc! ment doc <br /> — Ck <br /> EHD 29-02-001 <br /> 6/22/04 <br />