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o�quklN San Joaquin County <br /> z•` ? Environmental Health Department <br /> � =•j 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202- <br /> MITIGATION <br /> f, . (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd T IV <br /> �,FORN Well Permit Application 04 DEC <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED FILE GO" <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. 11 Assessors c.,17 e- e S <br /> o �. <br /> WELL Location D � L` �����?'^� r,�&C(ross Street City t1&.jj-tC4-• Zip clS-'3 6r7`S-'36r7Parcel# 0711 — O 30 <br /> TY <br /> OwOnerE Address 7:?l j!j 0j^%r N-t-" City S-uk Zip Phone# 6`r <br /> C-57 Contractor. Address Address a�� U WJec'X City-�Icv� Zip�%��f Lic# 615 Phone# <br /> -6on5Uttw*/Sub Cntr Waf W k)e l I TeanDAdd i b /�6 S�� City a t<�R Lic# -Phone# <br /> GIs Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: M w <br /> Q NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") Q'D�ESTTRUCTION (choose t�-'-- ,-a <br /> -� <br /> SOIL BORING# J f U C S <br /> Q WELL# <br /> Q`Other GROUT SPECIFICATIONS �v �# <br /> COMMENTS: n Z / _/ i� r .! / ' �'n W� t•y. ,,,h, <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS r• <br /> MONITORING Q HOLLOW STEM DIA.OF BOREHOLE Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS S +,O T TYPE OF CASING: Q STEEL $PVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> Q AIR SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes Q No (NOTE: MAXIMUM FREE-FALL.DEPTH IS 30') <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS <br /> OTHER:_O OTHER APPROX.BORING DEPTH <br /> 3 STOVEPIPE <br /> Q Q BOLTED TRAFFIC BO� <br /> I CONDUCTOR CASING PROPOSLD (if YES,list specificatior Q <br /> ons in co men section) <br /> COMMENTS: l5 <br /> b�-� f� <br /> NOTE: O SITE BORINGS REQUIREACCESSgeG-R�EMENTOR�ENCROACHMENT PERMIT <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 Ord' nces, Rules and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company <br /> Print Name GT C c� U)U- Dat <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: JAb2L�14 <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued Area 'r <br /> Grout Inspection By Date Final Inspection NEI=Date 5113 6S <br /> Destruction Inspection By Date — ��5 <br /> COMMENTSIC <br /> /CONDITIONS: �J Q <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> Dn oq- 1W , <br /> SR# D <br /> C-57_ WC -WA TVEP C-57 Letter of(Authorization to sign permit_Encroachment doc_ <br /> L•I-ID 29-02-001 <br /> 6/22/04 <br />