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an Joaquin County <br /> Envir m1nlental Health Department SITE <br /> 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 /> �t� QR Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED pplic o l 90?e <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This ain San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> f _r Cross Street er.%'r.�[.'^__City f4�� Zip `>-Y2& J f <br /> Parcel# 1 j V�fCc�7 <br /> WELL Location t/le <br /> 620 lAles+ Char�e�-W GtG d 3 SyIvc�nAv�_ Sqn 1�1ateo �14463 � <br /> i�-� <br /> �2 ER- --- Address `s� •Q ; lam,_ T G`' City erz-.,u.. Zip <br /> ` 'hone# �c--3'Par-t-� %�b'� <br /> Zip <br /> C-57 Contractor Address <br /> / �4 Swk23 u e Y?� <br /> `� �s d r <br /> Consultant/Sub Cntr Ce:• fir:._L t ;rf�,�t � dress ySY °'>-' n`� '_City-5e.- - Lic# Phone#7�'Z-r��'S- <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> A,NEW WELL/BORING' (CPT,GEOPR03E, HYDROPU NCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> a SOIL BORING# U OVER-BORE. DIAMETER <br /> 0 WELL# 2 - - 0 PRESSURE GROUT <br /> a*Other ~ WI7 -12-di`1�✓ -1 -S GROUT SPECIFICATIONS <br /> COMMENTS: - <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING i o;HOLLOW STEM DIA.OF BOREHOLE Sr Hrcp MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS ,5c 4,i'o TYPE OF CASING: a STEEL k'PVC a OTHER: <br /> 0 VAPOR p MUD ROTARY DEPTH OF GROUT SEAL`lam""¢¢ d.5 r b'i'g TREMIE TYPE TO BE USED. -i.AUGERS Q HOSE <br /> a AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ; Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: XOTHER APPROX.BORING DEPTH.50�. 7�kBOLTED 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 Ord* a ces, Rules and R gulati s, d all applicable California �Sttate Laws. � <br /> Signed �%''- '.- Title/CompanylL.I .-I( '�C/�t�� <br /> Print Name \ fl e� r� Date '`7 Z-5 /p'-7 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 2 0 W e 5 t G 1,1a y-t-i'er W2 <br /> WORK PLAN DATED: by e m 1'e' ) , 2606 <br /> `r n n� <br /> Application Accepted By Y i C+6 Y i a- Date Issued AP Y-;! 61.-�-U 6 -7 Area-Le 9 <br /> Grout Inspection By ��i r ?�^;4_�, ML/A,,•�t�ate 6`7 Final Inspection By Date q-12 -a 7 <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS:-Tyl StI ,�' to r' <br /> L <br /> NLY: AID# FAC# <br /> EE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> Sg 89. 00 �o4c'7 sR# poETC) ! 99 <br /> -57 WC_-WAIVER C-57 Letter of Authorization to sign permit Encroachment doc_ <br /> HD 29-02-001 <br /> 12/04 <br />