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• 0 <br /> N San Joaquin County <br /> Environmental Health Department SITE <br /> t 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 /> N" 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 application is made in compliance with San <br /> Joaquin County Development Title, <br /> Chapter 9-1115.3 and the Standardsofof Sly Joaquin ounty EnvironmeoEal Health Department. <br /> / 1 �j —� j,L Cwt) �- ssess0 <br /> Cross Street t City S'j"�'�{Z "ssessa, <br /> WELL Location C�..,_ <br /> PROPERTTI1(( 2t !D W• �� 71�! " }j <br /> Owner 1/oI D� lr(-4-44 .Address�iI Rilo�cfAYt�it city cS yf''�/�'� Zip SLI Phone# <br /> �reG15Iun ddress o$ S2x tl"'QcityJ a`'i'�9�T�r,#' Ph naW Z3 yS s <br /> C-57 Contractor k1w.s **-- �I9 <br /> Consultant/Sub Cnt?�qt"5a/ Address ZSa- wrl� -City f VAC Phone# 0=r 2 I !� 2 <br /> GIS Coordinates:XJ"1•9 3 2 1 ,Y l- V-3�j T� Range Section <br /> WORK TO BE PERFORMED: <br /> 71CN <br /> EW WELL/BORING (CPTJEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) D DESTRUCTION (choose type below) <br /> /11 OIL BORING# a OVER-BORE. DIAMETER <br /> ]WELL# 0 PRESS E GROUT <br /> O'Other UT Ee CIFIC TIQN✓S <br /> COMMENTS: y "7 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 ULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION )(AIR HAMMER/DRIVEN CASING THICKNESS_TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS O HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH D BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in com1ment section) <br /> COMMENTS: NecA+C11MlrnsE-'�n 2K* — rN ff2lt�( �:E!A✓cnAG I.. fhf ldA wd1T P f4JdJ <br /> NOTE: OFFSITE BORINGS REQUIRE ACCES,$ AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOT[ REQUIRED FOR INSPECTIONS. <br /> I hereby c ify th h e ared is a p atio at the work will be done in accordance with San Joaquin <br /> Coinanc , Rul and eg lations, d a able California State Laws. /1/I <br /> Signed x <br /> Title/Company ✓t ry'^'—" t <br /> Print Nam Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: Z 15-0 . C,11,11­74 t <br /> WORK PLAN DATED: z 3 C,6' <br /> Application Accepted By t r_ Date Issued Z 1 6 I P (a Area <br /> Grout Inspection Date L O b Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQt2!J <br /> Z qo1 '5 gq.0 v 7, 5-17- L,,t z b o6 SR# U C - <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permitf Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />