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�oPq�ly •San Joaquin County <br /> Environmental Health Department SITE <br /> a < 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> uFo 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 9-1111^5.3 and the Standards of San Joaquin County Environmental Health Department. <br /> t.Assessors <br /> �, -r /e-d• Cross Street City S f�iJ Zip Parcel# � (O / <br /> WELL Location-P25 II�� <br /> PROPERTY /�_ �� Cityjflb Zip 4hone# <br /> Owner 61 �- �� Address <br /> no <br /> G <br /> ontractor �y ) <br /> � Address <br /> �� 17YI04 City cl .n Lic# —� Phone# <br /> �o ant/Sub Cntr �J <br /> GIS Coordinates:X <br /> y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') U DESTRUCTION (choose type below) <br /> Q SOIL BORING# o OVER-BORE. DIAMET R <br /> E WELL GROUT <br /> GROUT <br /> GROUT SPECIFICATIONS qq,,,, ,,������ � <br /> O'Other <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> �Tv1ONITORING 0 HOLLOW STEM DIA.OF BOREHOLE�� U MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL ,�PVC D OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS p HOSE <br /> a AIR SPARGE/OZONE U PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS BOLTED TRAFFIC BOX or I]STOVE PIPE <br /> OTHER:_G OTHER APPROX.BORING DEPTH <br /> CONDUCTPR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: �/�`1K''"l�'� <br /> aJf'l� 5a,-(— e 3 f A)jW AP ®aco�at/ro( <br /> f,5 /?� ' yCec C-dam/ P ;�Lo /"-e, p a Ver --;�JJa <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 Ordinances, Rules and Re ulations, and all applicable California State Laws. <br /> Signed x Title/Company <br /> Print Name 5 �r/� Dale��nl D <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: /� G� ? �7 <br /> Application Accepted By <br /> l teno Date Issued J Q J l C OC6 Area <br /> Grout Inspection By <br /> Date Final Inspection By - Date <br /> Destruction Inspection By Date rN 2n <br /> COMMENTS/CONDITIONS: V-L <br /> .yt t'4[rtrt M O --0 <br /> ACCOUNTING ONLY: AID# FAC <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECT(BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> �c1 0O, Od IZ �J 3 sR# q Z6� UE:=] <br /> C-57_ WC=WAIVER_ C-57 Letter of Auth i i sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />