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FILE COPY <br /> RECENED WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> JAN 12 2004 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> ENVIRONMEIVT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> PERMIT/SERV!SFS ON <br /> NON-REFUNDABLE PERMIT EXPIRES i 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 Health Department. <br /> o1/Qi p� O/ Pascel#Assessors <br /> WELL Location-1/43 C�Lttd' .e3L14� Cross Street reAtlKU.JA✓tCity STdGKTO.J Zi <br /> PROPERTY /^! <br /> Owner .S'kn �2R1 Cn Address?.o. aOX 109106 City�T0"d-rb4 Zip96;49 Phone_# <br /> SS"3Li 0-- Phone# 9a 3/3-5-000 <br /> C-57 Contractor6P—r&C> TQIGCIAIG Address 150 s�DtJE 1DAD CityMA2T/aaZip`Z� ' �a� / 2 <br /> Consultant/Sub Cntr5EC0R.. =AIT:,-CA7C_Address3017 K/LC,o2E R�.CitJSACPAM`EuTDc# Phone#19161r�Io(-O�Q') <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> XNEW WELL/BORING (CPT,GEOPROBE HYDROPUNCH,HAND-AUGER,OTHER-) D DESTRUCTION (choose type below) <br /> $'SOIL B RING#4'18 -bI4 e- SIJ p OVER-BORE. DIAMETER <br /> ,,pp(�4N"•�ELL�e? �� d/A�'t " - xcjJ�¢J4 p PRESSURE GROUT <br /> `Other — '7 C' .ie GROUT SPECIFICATIONS <br /> COMMENNTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING '$.HOLLOW STEM DIA.OF BOREHOLE 12f p MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> 'EXTRACTION O AIR HAMMER/DRIVEN CASING THICKNESSSC/f 'PE OF CASING: p STEEL J&VC p OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL2! 3�� TREMIE TYPE TO BE USED: GAUGERS HOSE <br /> a AIR SPARGE/OZONE 11PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 4LYes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> p SOIL BORING a HAND AUGER GROUT SPECIFICATIONSN 5 3EN1ON/rE—t7zweo r c;-PexT MyXP <br /> g OTHER: Q OTHER APPROX.BORING DEPTH 5'5' GEE? $BOLTED TRAFFIC BOX or a 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 Ordinances, <br /> Rules andel Regulations, and all applicable California State Laws. <br /> Signed l/ `�/ o�/`J`�/��— Title/Company SC,-O� <br /> Print Name Thy //• /�'lCJ'.ftl.� Date C/ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: c17-1 0 -3 <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued D Area <br /> Grout Inspection By Date Final Inspection By l C��7L•�� tee <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR11 <br /> C-57 WC --WAIVER— <br /> C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br />