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San Joaquin County FILE COPY <br /> Mi) <br /> Environmental Health Department <br /> L= <br /> SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 MITIGATION <br /> UNIT IV <br /> (209)468-3449 Fax:(209)468-34" Web:www.sigov.org/ehd�'� <br /> Well Permit Application <br /> EN! fE i'N! 17 Z-7 El 7 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED "I 11 <br /> S <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 /> Assessors <br /> WELL Location ✓2CCN� VQI,��5f Cross Street city 5)-tc-K—,E,,j Zip c)5 i--,'-� --C z'_ - i -- <br /> Parceli 11 <br /> PROPERTY <br /> Owner <br /> ij(e r Address j5z��'-7 9 c,-t Cit 82i'Q Tl� Zilp c'5*�--Y Phone# <br /> C-57 Contractor c —Address S 5 Nvu s� 9'� . _)�I <br /> _CitY/,1Ar i:�fZZipQ,0.'>3 Lick_G.51 Y---7 Phone# 5) j_ <br /> Consultant/Sub Cntr Advanced GeoEnvironmental AddresS-B3-2-Shax-Rd—City-.Sitockton Lic#_fiB_Q2,2j Phone* (209)467-1006 <br /> GIS Coordinates:X Y Township. Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (�CLP�GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) Un DESTRUCTION (choose type below) <br /> ffSOfLBORING# 0 OVER-BORE. DIAMETER <br /> Q WELL# a PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: 5Ff_ /so / <br /> 2 -7 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING D HOLLOW STEM DIA.OF BOREHOLE Zi' <br /> _N 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS <br /> Zi!�_TYPE OF CASING: OSTEEL 9PVC OOTHER: 1jj11 <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL f;F4 �- TREMIE TYPE TO BE USED: a AUGERS <br /> Q AIR SPARGE/OZONE"PUSH POINT(GP orQET *OSE <br /> �GROUT SEAL PUMPED: Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> -,d'zOIL BORING A, <br /> fu�' a HAND AUGER GROUT SPECIFICATIONS. 7n f -T <br /> Q OTHER: nOTHER APPROX.BORING DEPTH 75 F&c, <br /> —0 BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED V/g specifications in comment section) <br /> COMMENTS: SEIEC '4P'P .-L-1 (if YES,list speci <br /> r( /��j <br /> 2 <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 Title/Company e C-1 �O %5/'>'7 Z4.�.L' <br /> Print Name j" Date - <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 3-P- 30 L Lan &_ <br /> WORK PLAN DATED:_ <br /> Application Accepted By p r C r�e,-. Date Issued -0'7 Area <br /> Grout Inspection Byj, <br /> �i Date.. .2-14-00 Final Inspection By. Vj'c,47-14 ate2 <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 I SERVICE REQUEST# INVOICE <br /> ° ,363. 04 -7// SR# L <br /> C05 7171 <br /> C-57— WC=WAIVEP C-57 Letter of Authorization to sign permit—Encroachment doc <br /> EFID 29-02-001 <br /> 6/22/04 <br />