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On Joaquin Cour,ty FILE COPY') <br /> `6 Environmental Health Department SITE <br /> y. 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 MITIGATION <br /> x <br /> � 'r'`' (209)468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> "�tFoR� Well Permit Application <br /> i <br /> NON-REFUNDACLE PERMIT EXPIR�.S I YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work desoribed. 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 /> Assessor <br /> p <br /> WELL Location ' l ! / % rr'=✓' Cross Street�wr+.+ K.cr City �� Zip Parcel# I -Z&O-1 C> <br /> PROPERTY ,� }� I ' ' 1, <br /> Owner�lo 931 c..�co ICy,t11 , Address�00 S It("01` City F--�{{.��;, ZiAIZD9 Phone# 1 "lb�^ I,S <br /> C-57 Contractor 4 t.��u�`1'''2 Address)OU 5� �- City1 Wz--s ZipgS641 Lic#A ZO�`fPhonet 16) }}}�-I/Oen <br /> Consultant/Sub Cnlr � -Lr"� Address63) )'�4/00 CitLALic# N�r�ttPhond-4IG�'�'�6-85 3 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: - <br /> XNEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER',,OTHER`) 0 DESTRUCTION (choose type below) <br /> E SOIL BORING# OVER-BORE. DIAMETER <br /> ANELL[I*Other <br /> 3! t.- ' 1 —� I, -� GROUT SPECIFICATIONS <br /> COMMENTS: 3 wa.wc> ^W �`^•"- ` '^ �LIf i 'J -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS n <br /> >(MONITORING HOLLOW STEM DIA.OF BOREHOLE��S, ••'' aMULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA:z_ <br /> []EXTRACTION o AIR HAMMER/DRIVEN CASING THICKNESS�c40 TYPE OF CASING: O STEEL PVC O OTHER: <br /> 0 VAPOR []MUD ROTARY DEPTH OF GROUT SEAL 7 -1;+.. TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> []AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes XNo (NOTE:M XIMUM FREE-FALL DEPTH IS 30') <br /> []SOIL BORING []HAND AUGFI2-------�GROUT SPECIFICATIONS N +A <br /> []OTHER: []OTHER APPROX. BORING DEPTH Z CU-R- a BOLTED TRAFFIC BOX or STOVE PIPE <br /> CONDUCTOR CASING PROPOSED ^1tw (;f YES,/'ISI Jpecifili i in comment lection) <br /> COMMENTS: 3 til JA> a� S1w �� d Co�-,y^j\••-•cT �.' �I-� --�V'Gq� <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 application and that the work will be done in accordance with San Joaquin <br /> Count Ord a c nd Regulati Ind all applicable California <br /> 1State <br /> (Laws. _ ♦ ,_ <br /> TitlelCompanyvw1�t , <br /> Signed x r� _1 ..l_,. •7 <br /> Print Nam �r^""¢-S 1 ` Q 1"' (-r `U� Date Z-C -N o V ^0 <br /> DEPARTMENT USE ONL — I, <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 4/ <br /> 0 <br /> WORK PLAN DATED: c��/ <br /> Application Accepted By - Date Issued 12-,1-0 / Area Q� <br /> Grout Inspection By_.._ Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/_ REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> D(� / ��340 SR# Q QCf2 <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit_Encro ment doc_ / <br /> �`�^� B� <br /> EHD 29-02-001 <br /> 6,22/04 FIL"OPY /I <br />