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G FILE COPT <br /> p,,'��•IN 4tan Joaquin -ounty <br /> SITE <br /> r.' Environmental Health Department�� <br /> 600 E. Main Street, Stockton,CA 95202-3029-4 �>n -X '�, /,MITIGATION <br /> m, <I (209)468-3449 Fax: (209)468-3433 Web: www.sjgov or0�tfd l/j , UNIT IV <br /> atrFo 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 plication 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 /> /S / � `/ Assessors/y��n� <br /> WELL Location Cross Street �� �6IPrCity/��Zip 95377 Parcel# 23801004 <br /> PROPE �M4b �1., p� -/ 77.77] <br /> Owner IdNI�AG((AC}��j}�i(,nJr{iJ W Address A/ w7 1 City I Zip Phone# Y-g9/- 6Z <br /> C-57 Contractor KJ� (,t./IQ Address Z20 P. Ea(f St�: Cjty"jw Zip�j UCA2-0i Phone# S/0:53 4-yZy <br /> Consultant/Sub Cntr Address 014 CityaidM� Lic# Phone#,!%illi7V <br /> 1 ,V r I <br /> GIS Coordinates:X:J!.707y �I't o of,Y ��ZI ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/ BORING (CPTAEOP 08 HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# j Y 7� 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> O'Other GROUT SPECIFICATIONS <br /> COMMENTS: -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_ 0 MULTIPLE CASINGS g MULTI-LEVEL WELL CASING DIA:------ <br /> a <br /> ____0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING OHANDAUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 7/ 0 BOLTED TRAFFIC BOX or 0 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 O n R sand Regulations, and all applicable California State Laws. <br /> Signed x Title/Company 4te �7 <br /> Print Na UST N �o6tr.RAr Date /�/QT <br /> DEPARTMENT USE ONLY / y(� • _ 2`-G <br /> SITE MAP IN UNIT IV FILE,ADDRFESS: 2532— <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued lo'��� Area NIP <br /> SZ <br /> Grout Inspection By _Date _ Final Inspection By Dale <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 /> ZYo� SR# ()051 0 <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign per Encrr mpeennt doc— <br /> EHD 29-02-001 web <br /> 6/22/04 (/ <br />