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coag N. San Joaquin County <br /> FC i <br /> Environmental Health Department ilf- I� ( SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehcfl,P;? UNIT IV <br /> Well Permit Application ENV1R10"wjt L;V- <br /> , r r. <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDE <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 /> �, f�� � .{ -Rssessors `J <br /> WELL Location J3� jj�. � Cross Street��..� ' CityL 7�t� Zip IS ��-�Parcel# v <br /> PROPERTY <br /> Owner //" fJ/}} L' Z Li .+���/ Address?q f iQ C City- cl J Zip C153)S Phone* CC lY�� <br /> C-57 Contracto4ji'L', ,Z�Q �( Address ���f /�• }'/ / City. Zip t Lic# 00'/ gPhone'#� \v ) 0C, <br /> Consultant/Sub Cntr rT re— ✓, Address��L63�!r�ar'� 'I Ci�y��Lic# Phone�m) <br /> GIs Coordinates:X Y Township _ Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> SWELL# r V"i.! 0 PRESSURE GROUT <br /> 'Other GROUT SPECIFICATIONS <br /> COMMENTS: -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING I HOLLOW STEM DIA.OF BOREHOLE5 L 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA �_ <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 6( TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: I Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONSt—� fC ? <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH % ' 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 /> 1 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 Ac4i: t <br /> Print Name ylV _ Date ! <5I ��Gl-7 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 67.1) f-{� <br /> WORK PLAN DATED: <br /> Application Accepted By �� Date Issued // 51 Area <br /> Grout Inspection By - Date L O Final Inspection By Date d <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 /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />