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f� <br /> San Joaquin County BILE COPY <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/elid UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to Sen 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. I` <br /> �90(p P El 0Or" 5I Cross Street 09105AI A , S� Aarceis <br /> WELL Location <br /> ,,Q( City Zip j _Parcel# <br /> PROPERTY V 1 qQ Bria3f wA C I <br /> Ovmer 1 �Y pll ! ( Address city ,l 666^1`1 ZI jj2 <br /> c p�Phone* <br /> C-57 Contractor 0 [WI I 11i (0 Address J ivF�t City LL ZiPLK Uc# W Phone#7rrl"37`/-t( L <br /> Consultant / Sub Cntr J't/AAVS �n Vi2 mjN �Gr ( Pr& C4»TLw <br /> C? Lt---Address 5vikfSC' City h Lic# Phone# 5,P-1/ ZE:ZD(cZ <br /> Gls Coordlnates; X3S , � ZI , v STI Zl .319 , Township ( yRa�geQZ Section <br /> WORK TO BE PERFORMED• <br /> n NEW WELL / BORING (CPT, GEOPROBE, HYOROPUNCH, HAND-AUGER, OTHER') DESTRUCTION (choose type below) <br /> a SOIL BORING # VER-BORE. DIAMETER loll n/ ' <br /> n WELL # PRESSURE GROUT 11 <br /> n `Other GROUT SPECIFICATIONS <br /> COMMENTS: hVLtdiitlyw-'l <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING ' IOLLOW STEM DIA. OF BOREHOLW,1011 n MULTIPLE CASINGS n MULTI-LEVEL WELL CASING DIA: <br /> g EXTRACTION n AIR HAMMER/DRIVEN CASING THICKNESSJ5 ski. VD TYPE OF CASING: g STEELIVC g OTHER: <br /> rAPOR n MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS a HOSE <br /> U AIR SPARGE] OZONE n PUSH POINT (GP or CPT) GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> n OTHER: n OTHER APPROX. BORING DEPTH a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (if YES, list specifications In comment section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS, <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County O_rdinanncesR�uJ(f(lte"s' and Regulations, and all applicable California State <br /> Laws, <br /> Signed x58Title/Company 64k5i5ir S GPH—Uvs, oy4t1 <br /> Print NameSCt44 <br /> 17 '�'��a�/ Date <br /> DEPARTMENT UCS/E� ONLY D ^ LDp <br /> SITE MAP IN UNIT IV FILE, ADDRESS : Ob W • CX <br /> WORK PLAN DATED: 6 ' <br /> Application Accepted By Date Issue <br /> Area <br /> Grout Inspection By. Dale Final Inspection y Date 0 Z6 0 <br /> Destruction Inspection By Date <br /> COMMENTS / CONDITIONS: <br /> ACCOUNTINGONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REM=CHECKII, , REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> SRO 5 59D <br /> C-57 WC.-WAIVER. C- 57 Letter of Authorization to sign permit_ Encroachment doe N <br /> EHD 29-02001 <br /> 6/22/04 <br />