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�oPQULN . `,San Joaquin County - <br /> z- �? Environmental Health Department EI;: ;`'.i:1,`; SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 F209)468-3433 Web: www.sjgov.orgtehd <br /> �q wP UNIT IV <br /> Fax: ( <br /> 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 /> Assessors <br /> WELL Location �� Cross Street el+ City Zip Parcel# <br /> Owner 2TY � t�� )brtC7 City =Zip`�v Phone# 210"1 <br /> Owner(D,,0 I Address <br /> C-57 Contractor ^^� � ddress �L/- X 3(o City --, ff��Z,,ip''946' Liic#-h�(N/ I Phonee##/' �T 44 <br /> �`�/ (?L <br /> Consultant/Sub Cntr�hA Y-,6y, TAC.. Address rl ity�Iky Lic#-46b�C�( P h o n e# /C��O�/ �� T'T <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> CNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> a SOIL BORING# a OVER-BORE. DIAMETER <br /> NWELL# 140- IQ .„( mw-1 b a PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> \' <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS .i <br /> .0MONITORING -PMOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS a MULTI-LEVEL WELL.CASING DIA: 2N__ <br /> a EXTRACTION o AIR HAMMER/DRIVEN CASING THICKNESSSCh '-fo TYPE OF CASING: a STEEL ERVC a OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 1- :re- A TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> Q AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes JKNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> o SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS T' 2T C&A­1CNvP <br /> a OTHER: OTHER APPROX.BORING DEPTH -e-4�OLTED TRAFFIC BOX or a 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 /> 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 a-,"�-State Laws. )' <br /> Signed x l/Y `1�'1�.) Title/Company F )lca t_S+- n��c;:ny,fa-kc 1'11,J1c, <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: v�19I <br /> WORK PLAN DATED:_/p2aw <br /> Application Accepted By ./(/ve( Date Issued fO y GS Area Ie s3 <br /> Grout Inspection By /I� Date D,& Q Final Inspection By C Date /P;�/ <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 /> G 6 <br /> 3S 3 j27e," 2�911)2 cl'111—IL SR# <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> 6/22/04HD2 -02-001 O <br />