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0 0 &an Joaquin County 0 <br /> Environmental Health Department �Q��v SITE <br /> m 304 East Weber Avenue,3rd Floor, Stockton,C � MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjg org/ehd O 5 2�0� UNIT IV <br /> Well Permit Application FE6 �Psu <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE IS �^���1EN R HCES <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work describe�?C hhxapplication is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joa�{uin Gouny Environmental Health/Deepartment. <br /> 23°lWG-� 41AUKft • -"- - crc r /1 zi '1,�-1 Assessors ® O <br /> WELL Location �'L��" 2.1�Cross Street ,{' 'C � /�y� �7p �i Parceelj���tso �l <br /> PROPEj2TY 0711 ddrste � 3 tJ I I City VAk Zip'"f1�U/ Phone# J �U �" '�`� I <br /> Owner 1f K1U <br /> C-57 Contractor_ _C g`�e1"-"""`�Address O' CI�.�rn�r�W Art iity Y,Ii/VZip_L A-_,Liaecw7 h� J T��2ZW <br /> Consultant/Sub Cntr&I ""./ Address tj" ) YKn� IIS!5�-' 'Ciy ic#I�1U O*7—Phone#-5W 33/--r <br /> GIS Coordinates:X .Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL I BORING JCPTGEOMDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> SOIL BORINQ# 1 O OVER-BORE. DIAMETER <br /> IWELL# a PRESSURE GROUT <br /> *Other GROUT SPECIFICATIONS <br /> COMMENTS: _ <br /> TYPE OF WELL 2l INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �lll <br /> ONITORING(3) a HOLLOW STEM DIA.OF BOREHOLE_'L a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA:_ _ <br /> M <br /> 0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL )(PVC a OTHER: <br /> a VAPOR U MUD ROTARY DEPTH OF GROUT SEAL 7 TREMIE TYPE TO BE USED: 0 AUGERS WOSE <br /> 0 AIR SPARGE/OZONE U PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> Q SOIL BORING a HAND AUGGE�R,,,�"� GROUT SPECIFICATION <br /> Q OTHER: OTHER 1jy r APPROX.BORING DEPT AX 5 U BOLTED TRAFFIC BOX or STOVE PIPE <br /> tI �J <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: A tgA w,4!4 cywy4ia/1 !�2 cut 6u'O' rPSI106 <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 /> County Ordina ces, Rules and Regulations, and all applicable California State Laws. <br /> Signed x i Title/Company IL.FJU t Kl� �� <br /> --Pflnt Name V(rv, Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FIL ,ADDRESS: aS3R a0 E �v� a I�4 1 <br /> WORK PLAN DATED: -tk- NJo <br /> Application Accepted By 1..J"1f f/ Dale Issued Area 9 q 7 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Dale <br /> COMMENTS I CONDITIONS: ( 1�A�1-(. C✓/Z.j CLC-15thS r n - Dom. 4X <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTEDCHECK# REC'D BY DATE PERMIT SERVICE REQUEST# INVOICE <br /> X1.01 a`I o�' ` d-186 -7 SR#CD / <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />