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4 ' fn1e <br /> a 4an Joaquin County • F I L F r R E <br /> c <br /> Environmental Health Department SITE <br /> ` 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd MITIGATIONUNIT IV <br /> `fes 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 applicatiF'sm"56 'omMa;teUw1anJoaquin County Development Title,Chapter 9-1115.3 antl the Standards of San Joaquin County Environmental Health Department.,�/ Assessors <br /> WELL Location 90� •Cflue7��LUf/� Cross Street �rPES�Of-!t>t;CI S%OLXTp�/ Zip 20(G Parcel# /(a3-020-/7 <br /> PROPERTY <br /> OwnerLle"rp W,-4,t CFlwrxru4(eC W-Address-3(o0 .41'Vdorw Be✓P City/&Aq 2-rd Zip! , Phone# <br /> C-57Contraclor PKE4,V&Y,5io' t/+/CAddress/o8/F,S-r�-X/ki&VNE City��c!/4.raW Zip9//�/ Lic#f/, Phone#S/O-Z37-</57j <br /> Consultant/Sub Cnt�e'�a4reri�a� zravaAddress2<WNetn5r, -;�&2/5 rCity?i2ESt/4 Llc# Phone#S5?-2(.e,125-35 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> -'NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> .KSOIL BORING#.S DOVER-BORE. DIAMETER <br /> p WELL# <br /> a'Other PRESSURE GROUT <br /> s p GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE Z a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:_ <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL u PVC a OTHER: <br /> a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 11 AUGERS a HOSE <br /> p AIR SPARGE/OZONE $PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ,It-SOIL BORING aHAND AUGER GROUT SPECIFICATIONS aEn/7-O.V/7 <br /> p OTHER:_0 OTHER APPROX.BORING DEPTH S n BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTSi5el/I30✓t/n60 7a aE /.t/Sr4i.LEa G(O 7a S'&;5 Gf,51Aa Z�/�PK�-/"amu N �Lf ppb �o.Q<N4S Grrc.c $E <br /> oA-cKFi Lr-e.D Wr7rf lSE�V7o.v/r't ' <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinanges an , and all applicable California State Laws. <br /> Signed x ''/{ Title/Company �/e 0J&-C7- F�4.,N/C,mpe <br /> Print Name �"a rr . 114-rrOnr Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: I (O Ld ��pc � z Cl)1Q tvJbCg' <br /> TO <br /> WORK PLAN DATED: -17- 2- <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection By to v <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> LACCOUNTING ONLY: AID# FAC# <br /> CODES FEE INFO EAMOUNTEj <br /> # REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 53 SR# <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />