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• 'op4�ty, o •an Joaquin County <br /> y z` Environmental Health Department SITE <br /> 600 E.Main Street, Stockton,CA 95202-3029 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/ehd UNIT IV <br /> q�rFa+=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,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental <br /> � HealthDepartm_ent. [ <br /> Assesso _I�o- <br /> WELL Location C. Po kee Cross Street City L-l�I Zipp-- 7) Parcel# <br /> PROPERTY ,�,,�LL II--,q�,,,,nnoo ff -- <br /> Owner Marl LLi JAL Address IV7004OCN`ir+W City t ( pp Zip OPhone# 33 ��0 <br /> C-57 Contractor QS Drill Address 010ec. ( r. City_4A Zip -Li c# V1 Phone 4C6 63Y-Ilb' <br /> Consultant/Sub Cntr N-E� Address `��� S V1 w City S+1- 40 Li�7_Phone45- 3ca <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> U NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) DESTRUCTION (choose type below) <br /> a SOIL BORING# p OVER-BORE. DIAMETER <br /> p WELL# PRESSURE GROUT <br /> a*Othern 1 GROUT SPECIFICATIONS 4 I �GW S <br /> COMMENTS: AW-151yttv'16 + /b1W 'I7 L1X'o{ a )a) C�p -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE_ u MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> p EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC 0 OTHER: r <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS a HOSE C <br /> 8 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING 8 HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER:_G OTHER APPROX.BORING DEPTH p BOLTED 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 Ordina s, Rul�Regulations, and all applicable California State Laws.n / <br /> Signed x Title/Company Prg'e-%)bI170C <br /> Print Name rl qM1� 1'✓yl� MRS <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: Mb s L^ AR' — <br /> WORK PLAN DATED: aSTcrpjac4c� '4-0 10 <br /> Application Accepted By �`�""" Date Issued �- It T/(C Area 9 7 7 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date n <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEEINFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> d9•o�— 60- 6cr �rr�� rel, _ sli 11) I SRO DD <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001web <br /> 6/22/04 <br />