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q�ly <br /> �o San Joaquin County <br /> It <br /> a+2'En�y <br /> rmental Health Department SITE <br /> ITE� 0 Easter er Avenue,3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> c4 Well Permit Application <br /> �/✓`ORa <br /> EP�V{r,Oh�l�'^,'�fT t-^.i T 1 6ff • COS <br /> ��7N-EtE�IJNU/�BLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> n ���•r� <br /> Application is hereby made to an Joagwn'Cotlr ty 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 /> Co try ('"b P,kvd. Assessors <br /> WELL Location�i+�/ IZ:l�t o-{- V"(4 Cross Street Ryle ��e- City'SivcI` v% Zip 95-20'1 Parcel# <br /> PROPER Y r f <br /> Owner ++� o{ S fork W&i Address y zSN. G( City Zip y5 -0`/Phone# Zy%'?3-7—S.21 Z <br /> C-57 Contractor re g` r'dl,nu Address 147 5- �s /hoz City5;��,�i 14,d Zip 9'2'V6Lic#65b rvyPhone# 56z—'19-7-6y`y7 <br /> ;�/ (Z <br /> Consultant/Sub Cntr CXLUhp rN+ey' a+;-;")Address"SO)7K,Icjt,.,e 2r.( 1#!a) City(ciµc>•J <br /> =l 1Lic# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERF RME4-, <br /> t;NEW WELL I RINGr dor'GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) Q DESTRUCTION (choose type below) <br /> SOIL BORING# C P f 3 Q OVER-BORE. DIAMETER <br /> ELL# K I 11 1—I 1-'\ Q PRESSURE GROUT <br /> 'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING Q HOLLOW STEM DIA.OF BOREHOLE z:S'-'r Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL Q PVC Q OTHER: <br /> -Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL 1/D Ft TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> Q AIR SPARGE/OZONE XPUSH POINT(GP or�GROUT SEAL PUMPED: XYes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS A le.it- <br /> G o w e n <br /> Q OTHER:_0 OTHER APPROX.BORING DEPTH /10 f t• Q BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED 4/0 (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 Title/Company <br /> Print Name r`'o. a (Uw.. —Date—Z <br /> DEPARTMENT USE ONLY L-�/ ' <br /> SITE MAP IN UNIT IV FILE,ADDRESS: L7�`� <br /> WORK PLAN DATED: O 24 <br /> Application Accepted By Date Issued <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 F^EEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign per Encroachment do 2 9/ 7 <br /> EHD 29-02-001 f os'-Ot w <br /> 6/22/04 / <br />