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,o UI San Joaquin County • `� , , <br /> ' Environmental Health Department SITE <br /> eta i9f ''' r �3aA� �ast Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> : <br /> - <br /> n,,,R0�le(;2�Q M9 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> o ' P-',vi . _ <br /> PE;;;, ;T,/SF`sVIGES Well Permit Application <br /> L <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 mad compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location a-7 7 33 CoAlv11 CrossStreet PyP Aw, City Sivck}ovl Zip 951R0y <br /> Parcel# /aZ i-z3o•-D/ <br /> PROPERTY <br /> Owner Va+woo. Coj, Re,-;i rY.G• Addresst`►19 &rakd Cak6l Glue( City 5fozOtA Zip 9 -A07Phone# <br /> C-57 Contractor 6 reqs D f M"µc, Address Z N'7 r Cerr +tr /V C City s y�lll;l/ Zip 90806 Lie#GS(�YO 9Phone# s b z-yd7-689% <br /> ...i 12 G�hUa Q <br /> Consultant/Sub CntrS1�LOJ? ed Address_30('7kkAgare a)­"+/V0 CityCO,'JOVII Lic# Phone# 916 V6/-0too <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 'NEW VyELL/B 1 (�GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) p DESTRUCTION (choose type below) <br /> OIL BORING# G T- �/ t OVER-BORE. DIAMETER <br /> WELL# Iec�'totil Wt S•I PRESSURE GROUT <br /> `Other GROUT SPECIFICATIONS <br /> COMME TS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> o MONITORING Q HOLLOW STEM DIA.OF BOREHOLE Z•S a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL p PVC a OTHER: <br /> a VAPOR o MUD ROTARYDEPTH OF GROUT SEAL /10 TREMIETYPE TO BE USED: U AUGERS 17 HOSE <br /> AIR SPARGE/OZONE PUSH POINT{rGP c1rT)GROUT SEAL PUMPED: ®Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING Q HAND AUGEt[j//l I,' GROUT SPECIFICATIONS /ye'*'t C e k'+en-f <br /> OTHER: 1 1Cwf]OTHER t APPROX.BORING DEPTH J10 BOLTED TRAFFIC BOX or O STOVE PIPE <br /> IiI�Q� CONDUCTOR CASING PROPOSED /f-/O (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 /> hereby certify that 1 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�- %— Title/Company } �`�f 6N��s/ <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> a-s <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 49A <br /> WORK PLAN DATED: -v <br /> Application Accepted By Date Issued 3`2- _d S Area oICe'V <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encr /���ment doc_ <br /> EHD 29-02-001 g!1A 4Z-' <br /> 6/22/04 <br />