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' San Joaquin County copy� <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> ' (209)468-3449 Fax: (209)468-3433 Web: www.sigov.org/ehd UNIT IV <br /> Well Permit Application <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 /> 6I <br /> n,,.1 �p,,� �/� A��/ a��111 Assessors <br /> WELL Location int) W. b'{NJ 90 Cross Street�.UINMU5 Q..00Ity Tef'V 1 Zip*3 rn Parcel# �3�'��0'VZ <br /> PROPE 1- <br /> Owner Vin 0.40►JfSIC i Address_ 321ow• MON R09(�ity rl?AG`f Zip q `) hone# 209• '63L63uo <br /> ' C-57 Contractor O(nL,(Lt INCA Address 2202p916P5'A C Cit Zipj 1%Lic#f q hone#C6,?D,6b9.24Z4 <br /> Consultant I Sub�Cn�ttr�S1'�IL, �y AddresrydNO WA9K1e J1E�JCIty c# tJ A Phone# alb qj+'-! PDw <br /> ' GIS Coordinates:JFIf 1 t 31� o ,� 121.7173,Township Range Section <br /> ORK TO BE PERFORMED: <br /> EW WELL/BORING CPT,G QQ,R�Q E,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> ' OIL BORING# �-I tl'N� a OVER-BORE. DIAMETER <br /> WELL# a PRESSURE GROUT <br /> (]'Other GROUT SPECIFICATIONS <br /> ' COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPEC( (CATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE V a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: 916_ <br /> ' Il EXTRACTION u AIR HAMMER/DRIVEN CASING THICKNESS tJMI�AA�rr�� �r1y,�TT�YI.PvE_OF CASING: U STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR Il MUD ROTARY DEPTH OF GROUT SEALVMr�( T&Mr1 TREMIE TYPE TO BE USED: []AUGERS eHOSE("Sr" <br /> p AIR SPARGE/OZONE USH POINT(GP or CPT)GROUT SEAL PUMPED: U Yes 0 No (NOTE: MA7y�IIMUM FREE-FA DEPTH IS 30') <br /> "HOIL BORING HAND AUGER GROUT SPECIFICATIONS U rgkr YAWT I.O' WWITO <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH .�6 61 a BOLTED TRAFFIC BOX or O STOVE PIPE <br /> CONDUCTOR CASING PROPOSED MIA (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 pr pared this application and that the work will be done in accordance with San Joaquin <br /> County Or ' ces, Rules Re ulatlons,and all applicable California State Laws. J( �y} <br /> ' Signed x Title/Companyij NUI M �LI N1157' I`y�J <br /> Print Name <br /> DEPARTMENT USE OnNLLY'�J ' t r <br /> SITE MAP IN UNIT IV FILE,ADD SS: rwp! N C. tf- G' <br /> WORK PLAN DATED: i <br /> ' Application Accepted By Date Issued rea a <br /> pe <br /> Grout Inspection By D e 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/SER%nCS REQUEST# INVOICE <br /> 2?-01 / -31-7 SR# <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encment doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />