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p ... San Joaquin County -' <br /> )OiQa <br /> _• a Environmental 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 UNLT, IV <br /> c <ikoRcr`P 4� O•G(r <br /> Well Permit Application �r�r <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 madliaryvith San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. 0 <br /> ,C,, Asset =f <br /> WELLLocation &!5i5;;c4& /L't- Cross Street City Zip9s�3�Parce*tr <br /> OwOerEn nix Address��r�k' City Zip Phone# ��0 <br /> C-57 Contractors( `/- /`'(-� ���Address&d'ky 23 LIn CityyA, r Zip�Lic# Phone# - v' j�Jv <br /> Consultant/Sub Cntr /C &, 1 ' -&r - Address_�K.>$7� 7Z,� City_.5�1Lic# Phonet�c9`ll�O / � <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ` MEW WELL/BORING (CPT,9EOPR9BE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> SOIL BORING If ��$@�— • '�/� _ Yf a OVER-BORE. DIAMETER <br /> ]OWELLther# a PRESSURE GROUT <br /> �- ' jP Z 5/ 12, t GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> l'YAIE !( <br /> � ONITORING {OLLOW STEM DIA.OF BOREHOLN MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> //0``'''EXTRACTION ,a AIR HAMMERIDRIVEN CASING THICKNESSTYPE OF CASING: Q STEEL VVC 0 OTHER: <br /> N VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL S— TREMIE TYPE TO BE USED: $,AUGERS Q HOSE <br /> Q AIR SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes kNo (NOTE: MAXIMU <br /> M FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS 'A je �� <br /> Q OTHER:_0 OTHER APPROX.BORING DEPTH � OX or Q STOVEPIPE <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 Ordinances, Rules and Regulations, and all applicable California State Laws. / <br /> Signed x 4 <br /> ) Title/Company �X�/ �l "•'�-� <br /> Print Name r� /l�Q� Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection B ate <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REWD BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 210 , _pij s " ov �:� I <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment docA <br /> EHD 29-02-001 <br /> 6/22/04 <br />