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' San Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> ' *P­ <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 Envi�ron,�m�{ental Health Department. <br /> ' <br /> WELL Location <br /> Y8I /��� swS�s Cross Street �J�' ;ity_ 1rfiVl__Zip g6�/11 Parcel# N- 0-m <br /> PROP n ffu / 110 L� (�,�weltW J �(o Aft! aK 1 p C O <br /> Owner ll;;nn - �I�uol��gtldress I IGDY ry•WwA,1.4Fw lyk7 City IFrIVI Zip IV 1'1 Phone* -I '/Jr Y� 'f <br /> ' C-57 Contractor g6l D12-II.(dg Address 22011•Efkii City, �Zip�Lic# �2' phone#1.7 Z�ZY <br /> Consultant/Sub Cntr SI iL Addrerrrs���syyy���ijeee����00 WI k ."' Citj''tJ1GLic# I-jA Phone# 4Ib U p� <br /> GIS Coordinates:iNT7: 3;t TT97 Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING CP GEOP�tf�BE,HYDROPUNCH,HAND-AUGER,OTHER-) n DESTRUCTION (choose type below) <br /> ' F O„BB#ORING# S�•7j 151 A DOVER-BORE. DIAMETER <br /> PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: <br /> ' TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPE IFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE P MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> n EXTRACTION n AIR HAMMER/DRIVEN CASING THICKNESS- W10 TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT qFAIbE?I`4 Y 1r I16REMIE TYPE TO BE USED: 0 AUGERS MHOSE 1G730-) <br /> 0 AIR SPARGE1 OZONE VPUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXI UMpFREE-FAL4 DEPTH IS 30') <br /> GEMEQ" <br /> SOIL BORING aHAND AUGER GROUT SPECIFICATIONS ryI;Rf J pC'f✓ICJ11 t(IiJ <br /> ' 0 OTHER:_0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 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 /> ' I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinan Rules and Re dations,and all applicable California State Laws. \n <br /> Signed Title/Company IRJJFLT' 1;N WoAmr—tirAL <br /> ' Print NameDate <br /> 1 UkJI <br /> DEPARTMENT USE ONLY <br /> ' <br /> �,q ZSJ.60 SITE MAP IN UNIT IV FILE,ADDRESS: '/ ?05 �/r (/R,, <br /> WORK PLAN DATED: 9.O <br /> 'Application Accepted By Date Issued �� Area Ui <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> 1; <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED ;;6 <br /> REC'D BY DAT PERMIT//SERVICE REQUEST# INVOICE <br /> o �Y <br /> 'C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign ermit_Encroe�.m,�e-nt docT B <br /> EHD 29-02-001 �SiWI'� <br /> 6/22/04 (/ <br />