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San JoaquiwCounty f 11 F C <br /> , <br /> Environmental Health Department SITE <br /> td East Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> � -3449 Fax: (209)4683433 Web: www.sjgov.org/chd UNIT IV <br /> iraa� Well Permit Application <br /> NOV <br /> NON-REFUNDABLE PERMIT EXPIRES.1 YEAR FROM DATE ISSUED <br /> Application is EWMMENjn*Ajt4ounty for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County �RVter 9-1115,3 and the Standards of San Joaquin County Environmental Health Department - <br /> Assessors r r <br /> WELL.Location (' ow-}-� �t Cross Street 2m--b City- TOZip Parcel# <br /> PROPER ;f-tom ; !� <br /> Owner ISMAZL �V Address }✓< S1U(�ST. City S�Pbg ZipCISW6 Phone# <br /> 4 <br /> C-57 Contractor I�I�'Ko Address ( Ci vIZi�/ �ic##�Phone# S30�- 3-all <br /> Consultant 1 Sub Cntr �-- Addressz2-V�MORE P A0Z Ci L "" lrr ItiLic#ADZ7vZ-Z- Phone#C{LS-( OQL- <br /> GIS Coordinates:X Y j Township I �j Range Section <br /> WORK TO BE PERFCIRAM ` t <br /> NEW WELL 1 ORII (CPT, EOPROB HYDROPUNCH,HAND-AUGER,OTHER*) DESTRUCTION- (choose type below) <br /> ©SOIL BO a OVER-BORE. DIAMETER <br /> a # i 0 PRESSURE GROUT <br /> O fie ! <br /> GROUT SPE=CIFICATIONS <br /> COMMENTS: x <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE p MULTIPLE CASINGS .0 MULTI-LEVEL WELL CASING DIA: <br /> e <br /> ©EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: O STEEL B PVC..O OTHER: <br /> a VAPOR ©MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br /> a AIR SPARGEI OZONE ,PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> XSO1L BORING D HAND AUGER GROUT SPECIFICATIONS .i. <br /> a OTHER: n OTHER APPROX.BORING DEPTH 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 /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinarwss, RE les a`L�tdd Re ulations, and all applicable California State Laws. <br /> Signed x Title/Company <br /> _ E <br /> Print Name s Date vlro <br /> Mlffwl3 USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: Z�0 <br /> Application Accepted By Date Issued 12p, r Area <br /> Grout Inspection By Date Final inspection By` <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES ' FEE INFO AMOUNT REMITTED CHECK# REC'D 81 DATE PERMIT/SERVICE REQUEST# INVOICE <br /> v6� -a sR# �o <br /> Wd <br /> C-57tl/_ CC WAIVER_ C-57 Letter of Authorization to Sign permit_Encroachment doc +V <br /> EHD 29-02-001 <br /> 6/22/04 I <br /> t i <br />