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rQUi <br /> ,� ro Can Joaquin County <br /> Envir , nental 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 <br /> EB, UNIT IV <br /> Well Permit-Applicatioq%F f P� 3: 25 <br /> NON-REFUNDABLE PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the;k�000,00 <br /> Ihis rc�tilSn is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and khe Standards of San J6aquin Cou- , All lth department. <br /> f I <br /> r " � �� Assessors � <br /> WELL Location 1119 rid,9Q.IfkLr�� Cross Street&�{ �P�"-City Zip��Pareel#_ <br /> PRO'E .•` <br /> Owner QaJ G Address City &U?— Zip.9�52kO Phone# 2 S <br /> C-57 Contractor VQ,r od ty&&V1fVq e d Citys [K Zip Lic# D 2 P h o n e# <br /> Consultant/Sub Cntrhdftad 4kt&fij2Ukej4ddress 937 Slta&o . K4 Cit�_Lic#�� <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL 1 BORING (CPT, PROBE YDROPUNCH, HAND-AUGER,OTHER-) p DESTRUCTION (choose type below) <br /> WSOIL BORING# a OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT M <br /> 0*Other GROUT SPECIFICATIONS d <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA"OF BOREHOLEL.—gr'.O MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSu �! YPE OF CASING: 0 STEEL . 0 PVC 0 OTHER: <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL. 0 �v�al TREMIE TYPE TO BE USED: D AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: D Yes XNo (NOTE. MAXIMUM FREE-FALL DEPTH IS 30) <br /> XSOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS?lW R&d _ <br /> 0 OTHER:_0 OTHER APPROX. BORING DEPTH fir. 0 BOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED 14o (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 Or s, es e , an all applicable California State Laws. <br /> .Signed x Title/Company lG — /Sy-sw �~ <br /> Print Name Date �� D(p <br /> DEPARTMENT.USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By 0,,j Date Issued 1� T®D �j Area <br /> Grout Inspection By Date Final Inspection By T Date. <br /> Destruction Inspection By Date <br /> COMMENTS i CONDITIONS: <br /> ACCOUNTING ONLY: AID# F <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'O BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> 2t SR# . Ly <br /> - <br /> C-573 C 1�/AIVD 4. C-57 Letter of Au"thokzati n o'sign permit Encroachment doc <br /> EHD 29-02-001 <br /> 6/22/04 ff <br />