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�n U'+Y Noq 2.1- San Joaquin County COPY <br /> ,�A <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> 1' (209)468-3449 Fax (209)468-3433 Web www s3gov org/ehd UNIT IV <br /> �R rf;=OR 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 wnd/or install the work described This application is made in com +ante with San <br /> Joaquin County Development Title,Chapter 9-1115 3 and the Standards of San Joaquin County E=nvironmental Health Department <br /> Q,, &,Vivo' AV£ Assessors <br /> U <br /> WELL Location (6�713 W, &Aiw OVA' Cross Street illo w D City �O, Zip 9r2ySParcel# C7S5 _)-cZJ <br /> PROPERTY r C <br /> Owner AACDqj0ALjDj C4/? , Address 70 Q GAS F- thh&r,ty L,n`n A" C'p"(091 Phone# f(6 � ^g 0 6 7 <br /> a DAVE. <br /> C-67 Contractor C St inn Address363Z 0141!C. Cift:.�� C+tyCaaenn,4 Zip�7yZVc#717Sra Phone# <br /> Consultant/Sub Cntr R.G. Address 5N RD CtyST,xlr;ar. Lic#ArdOZZ 7 Phone -4 (/ -/.0,3b <br /> GIS Coordinates X 'y Township Range Section <br /> WORK TO BE PERFORMED <br /> Y,NEW WELL 1 BORING (CPT GEOPROBE HYCROPUNCH,HAND-AUGER OTHER") p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 11 a OVER-BORE DIAMETER <br /> WELL* '"7-0 v D PRESSURE GROUT <br /> `Other, GROUT SPECIFICATIONS <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFIC NS <br /> MONITORING k. .OLLOW STEM DIA OF BOREHOLE-10" MULTIPLE CAS1N G MULTI-LEVE=L WELL CASING DIA Z�� <br /> E EXTRACTION g AIR HAMMER/DRIVEN CASING THICKNESS P , 0 TYPE OF CASING a STEEL APVC Q OTHER <br /> 0 []VAPOR p MUD ROTARY DE=PTH OF GROUT SEAL TREMIE TYPE TO BE USED XAUGERS 0 HOSE <br /> a AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED `S7'Yes 11 No (NOTE. MAXIMUM FREE-FALL DEPTH IS 30') <br /> D SOIL 13CRING p HAND AUGER GROUT SPECIFICATIONSl� a T D Z'XAZ <br /> d OTHER n OTHER APPROX BORING DEPTH 5'.1" BOLTED TRAFFIC BOX or d STOVE PIPE <br /> 5�.. '` CON 'CTIOOR W y1 GP7POSE�D Ah- (if YES list specfications to comment section) <br /> COMMENTSP c} T} 9 r� <br /> MOTE_ OEES17E EORiNGS 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 Ordinances, Rules and Re ulatlons, and all applicable California tate Laws <br /> Signed x itle/Company T T 15=r____ <br /> lr V I Date <br /> Print Name � <br /> DEPARTMENT USE ONLY C� / ,-�,, n 4 US)- <br /> WORKSITE MAP IN UNIT IV FILE,ADDRESS. 6�Zt W ' 2-V'_5f �� Ql2,8 '� Cf LJ US) <br /> WORK PLAN DATED' ArCLR O , <br /> Application Accepted By 15�� Date Issued_ Area m O <br /> p <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS <br /> ACGOUNTING ONLY AID# FAC# <br /> 0 PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DA'T'E PERMIT/SERVICE REQUEST# INVOIC° <br /> 2.R-til SR# 06 �3d <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign pertnit Encr Ment doc ✓ f <br /> EHD 29-02-00t <br /> a . <br /> 6/22/04 <br />