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�= FILE COPY <br /> San Joaquin County <br /> 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 UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED D1 V <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 Health Department. <br /> WELL Location "2-\O�-S ". Cross Street kKo v )"' City_,�„}sr„� Zi Assessors <br /> PROPERTY C.A�r�1O 6\v6 A� C-� p Parcel# 13L Olt 02_1) <br /> Owner-pn°,ev— SOAddress "�S 'S S W'�,, V m City _Zi %-A <br /> Phone# <br /> C-57 ContractorAddress : kttftc# S1&on <br /> Consultant/Sub Cntr QS6L ddress Ll� City <br /> hone#k tk <br /> ^ <br /> GIS Coordinates:X Y �aCA,wNX t.A <br /> Township Range Section <br /> WORK TO BE PERFORMED: <br /> KNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION (choose type below) <br /> B SOIL BORING# <br /> SWELL# _ '�C IAC 0OVER-BORE. DIAMETER <br /> O'Other IP C.e t .ye a . 3L�'"- O 11 PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: <br /> b� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 'MONITORING RHOLLOWSTEM DIA.OF BOREHOLE_ VAULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: KAUGERS <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 HOSE <br /> g Yes p No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: H OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> COMMENTS: <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> C,�•c�c _ t,.a J.Y (X_ 2 <br /> 1�i1 r:S- 2 a....'A C CJI. <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 <br /> ���� Title/Company_ <br /> Print Name_ T—� — 3 Date Co 1 2Up I oto <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 21p �2 a� <br /> WORK PLAN DATED: <br /> Application Accepted ByDate IssuedVOb Area <br /> Grout Inspection By, ate_ Final Inspection By Dale <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> WACCOUNTING ONLY: AID# <br /> FAC# <br /> S FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICESR# pfWC_ <br /> C-57 Letter of Authorization to sign permit_Encroachment doc 1� <br /> EHD 29-02-001 <br /> 622/04 <br />