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11 San Joaquin County <br /> a -- <br /> �' Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor,Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 rWeb: www.sjgov.org/ehd q- � � UNIT IV <br /> AOR 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 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 /> r{1, �L y Assess <br /> WELL Location 103 Ly17,. I 1 71(0 0 1 Cross Street City ZtP 9�Parcel*1521'1330 A j <br /> Owner PROPER�l31 IA r\ I CA 'I Address 179a glaj'i�'Dr �' ,,��,,,, [�0 -61 3:;L <br /> —_ V.� I �f C ^ ' City—ca.L PL .y�i,�Phone# /" <br /> C57 Contractor As Address Z20 5hd KOICityZipqC&'ffUc# 5/ <br /> "QWhone#(A0V �1,77j-Q& <br /> Consultant/Sub Cnt&(7J Address$37 r5 CityI c*4aW- _7 Phone# 6/ —16-&b <br /> GIs Coordinates:X_Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> O NEW WELL/BORING jCPT GEOPROBE, YDROPU CH,HAND-AUGER,OTHER-) D DESTRUCTION (choose type below) <br /> SOIL BORING# LI �,r D OVER-BORE. DIAMETER <br /> D <br /> " WELL# ll}- D PRESSURE GROUT <br /> a*Cther GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING D HOLLOW STEM DIA.OF BOREHOLE—°D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: " <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL D PVC BOTHER: <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL 'rD A:.QVZTREMIE TYPE TO BE USED! D AUGERS D HOSE <br /> D AIR SPARGE/OZONE XPUSH POINT(GP or CPT)GRCUT SEAL PUMPED: D Yes XNo (NOTE: MAXIM FREE-FALL DEPTH IS 30') <br /> SOIL BORING DHAND AUGER GROUT SPECIFICATIONS TO&I :b1pt IL1 <br /> D OTHER: rl OTH/ER \ APPROX.BORING DEPTH O�W� BOL D TRAFFIC BOX or D STOVE PIPE <br /> COMMENTS: (,ZL) a.,� �(,y � QVDUCTOR 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 I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County O inances, Rules and Re ulations nd all applicable California State s. <br /> Signed x C / Tit, Company Q <br /> Print Name DahwS <br /> a. PX-I-ov� Date IQL 447 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: �. 7 <br /> WORK PLAN DATED: 11 I O q(6 <br /> Application Accepted By ��� - -�l-R,tr-t� Date Issued I!2-I '9 I Q Area <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 /> 2-`lnl 1AN72 1 1 !at o 4 SR# y04a <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> E1D 29-02-001 <br /> 627/04 <br /> FILE COPY <br />