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1 <br /> 4 <br /> San Joaain toun y _ <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 1V <br /> 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 applicati is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Healtq..pepartment. y. <br /> 2705 Coy,,, C 6 Assessors. <br /> WELL Location , �+, t3l1lc( Cross Street City S k�r/h Zip'9I 10 4 ParceW <br /> PROPEcT" <br /> Owner Address •� 49W, 4icitY9X14V <br /> Zfp Phone# <br /> j�j-�F ? <br /> C-57 Contractor 2e5o� SO'v c Address 120 City4pael &J zip 9E77 6 Lit#SIJ)33t P one#V)(o(,� 14y1� <br /> Consultant/SubCntrSl.,til.,� Enwlatiw►cKk( Address1W �vb, Pr.k i)r, C �`� 9IL r,� <br /> 0Y y� Lic# Phone#� �S�7` I`� <br /> GIS Coordinates:AA +- 37 403 ��/Zf.'}3il ,Township I A/ Range G E Section_,S <br /> WORK TO BE PERFORMED: <br /> )(NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") p DESTRUCTION (choose type below) <br /> 0 SOIL BORINrI 0 OVER-BORE. DIAMETER <br /> lh"ELL#" - .. kil a PRESSURE GROUT <br /> n-Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> . 4-9 t W4!A) d! <br /> TYPE OF WELL IN—STALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLEJE! M <br /> �MULTIPLE CASINGS �MULTI-LEVEL WELL CASING DIA: Z <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SCH YO TYPE OF CASING: U STEEL (PVC BOTHER: <br /> 11 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 3 4� TREMIE TYPE TO BE USED: Q AUGERS '&HOSE <br /> 0 AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: JKYes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 11 SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS Ct^14� <br /> 11 OTHER: <br /> _ APPROX.BORING DEPTH I )(BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED QS (if YE ,lis pecifications in com t section) <br /> COMMENTS- 1/ <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 OrdinancXisftles and Regulations,and all applicable California State Laws. r t� I <br /> Signed x Title/Company NVQ 44 Geotw , S j C.�Ld�ra h Wlf MI <br /> Print Name Al qm btlk,y <br /> Date 3/27/0-T <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> 77 <br /> Application Accepted By Date Issued .5 y'- 0-7 <br /> Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date e <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO If AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REtIUEST# INVOICE <br /> SR# <br /> C-57 WC=WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc l� <br /> EM 29-02-001 <br /> 6!22/04 FILE COP Y Ax)QV-&y_ <br /> o�� <br />