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r <br /> FILCOPY <br /> q <br /> an Joaquin County <br /> : .. sW, o . <br /> `' Environmental Health Department sit <br /> W ��EU4 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 /> 9 2006 <br /> Well Permit Application <br /> f ENVIROMiiENT H❑EAL 0-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED � �� <br /> Application if6P"tt SEF+N aquin County for a permit to construct and/or install the work described. This application is made in comp)ante with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Ab-sp[r-031'TI) �� -�nJ�Assessorr- <br /> t <br /> WELL Location T . �, �l , _� Cross Street J �� City Zip �4d✓},'�arcel# . <br /> PROPS r `6 <br /> L <br /> Owner ��oFl S �cj, ypj Address 2(��rE� Wp - A96 City S_10[��!4 ZiFC2 honet(2t i)9,3- ``-% <br /> C-57 Contractor = R�f3.t- Address { ,V_ �[J City�1J' VIU Zip 1. <br /> gi2VO Lic#HO'4 Phone 53a 5 _9" <br /> Consultant/Sub Cntr_L t / _ <br /> GIS Coordinates:X Y Township tA Range Section <br /> WORK TO BE PERF ; <br /> NEW WELL 1 ORING rrPT. OPROB HYDROPUNCH..HAND AUGER:OTHERn n_DESTRUCTION P^hoose type helrnvj <br /> SOIL BOR G#�:S Q OVER-BORE. DIAMETER <br /> a WELL# /f q 0 PRESSURE GROUT <br /> a*Other x GROUT SPECIFICATIONS <br /> COMMENTS: <br /> i. TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING o HOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS G MULTI-LEVEL WELL CASING DIA:_�� <br /> 7 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL a PVC a OTHER: <br /> VAP* p MUD ROTARY DEPTH OF GROUT SEAL - `" TREMIE TYPE TO BE USED: a AUGERS o HOSE <br /> Q AIR SPARGE!OZONE XPUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes ©No (NOTE: MAXIMUM.FREE-FALL DEPTH IS 30') <br /> ASOIL BORING Q HAND AUGER GROUT SPECIFICATIONS 3 <br /> OTHER: I7 OTHER APPROX,BORING,DEPTHS a BOLTED TRAFFIC BOX or ©STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br />{ <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. + <br /> 48 WORKING HOURS NOTICE REQUIRED-FOR INSPECTIONS. <br />{ r <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordip es, les and Regulations, and all applicable California State Laws. <br />! Signed x TIlIelCompany t✓/1-Ift't'b <br /> b _ Pr nt Name 1)!�'V^'/'S 4 7r- �o b <br /> ia1G <br />{' ��DEPARTMENTrrUSEONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: l l 'E ( xo����"l eze <br /> WORK PLAN DATED: U <br /> I Application Accepted By Date Issued "' Area <br /> Grout Inspection By Date Final Inspection By A' ate <br /> I Destruction Inspection By Date <br /> E <br /> COMMENTS I CONDITIONS: <br /> f ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br />{ 1b2�4 4 SR# : d . �8o;E5 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encr000 ment doc� <br /> EHD 29-02-001 <br /> 6/22104 JJJ���7 5 <br /> ` <br />