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0 i FILE COPY <br /> �o u M San Joaquin County <br /> a a <br /> Environmental Health Department SITE <br /> a � 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> (2: 9)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd 2(70-41APT2W PH ': 04 <br /> <1F0 Well Permit Application Nftrl i <br /> 44 -r,E..'. <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED EN ti hvrc LN 7T AL <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is ma�cEicle��IfaBd�e vil�tt#5art�rvYw? T <br /> Joaquin County Development Title,Chapter 9-1[115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> i �yo� 6'btd�a5p}tT `l 'rpwuLeu t�orty SIC P70 Zi iS338 Parcel#rsl��-3$0 0 / <br /> WELL Location i t e Cross Street Ci p <br /> PROPERTY//rr�11 t )1 ! p / aS33o <br /> Owner <br /> PROPERTY, <br /> C-FLf/7�1j.� Address 1b7'1S 7/rw'iag bi City hdt�/b Zip Phone# A)1-'Fql 7yy7- <br /> C-57 Contractor .Sik�C`�ruhl Address r�3fo� 0° cu'� .,1r1�r City 5�k� Zip�K7�5�Lic* 51�0�° Ph GG <br /> Consultant/Sub Cntr KltetsAe�{f Address Add' Pfyr�je City jZ1Kk Lit# Phone# �l{o- y3 � <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION (choose type,, <br /> below) <br /> 0 SOIL BORING# JrOVER-BORE. DIAMETER 8 <br /> pWELL# MWM-%D a PRESSURE GROUT <br /> a-Other GROUT SPECIFICATIONS IJe&4'IfO0a49`r <br /> COMMENTS: RIUM 10 IS 2 p�C "fc{c� ! <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> `MONITORING a HOLLOW STEM DIA.OF BOREHOLE_ o MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA:------ <br /> a EXTRACTION o AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: U STEEL it PVC D OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS O HOSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING o HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_O OTHER APPROX.BORING DEPTH g BOLTED TRAFFIC BOX or U 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 Ordin nces, Rules and Regulations, and all applicable California State Laws. <br /> Signed xhd' °(-/ ! "",'/ Title/Company rid `{ <br /> Print Name <br /> Y(�.t�VCtS F' edW Date 3/a?!b'7 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: //Date Iss #'I' '�� 66� <br /> Application Accepted By �, <br /> Grout Inspection By Date F' al Inspect! Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> [ACCOUNTING ONLY: AID# FAC# <br /> E CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> �• ' /3052 3 L6 SR# 0 6 lih� <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_Enc� t doc�_ /- 0� <br /> EHD 29-02-001 <br /> 6/22/04 <br />