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1 <br /> San Joaquin County J <br /> 5)f Environmental Health Deparl At =_—' SITE <br /> N' 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgoNQi 4ehd ,- ' UNIT IV <br /> �;FORa Well Permit Application EMh <br /> p <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,1� <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, <br /> Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> r! Ul y�� Zip �6 Assessors <br /> WELL Location / Cross Street Cit Parcel# <br /> PROPEER�TY � ,`�, �L p <br /> Owner/A GLLl�7c� � Address IA 65.�T• SA A City� k'Zipb f. Phone# <br /> C-57 Contractor ( Address P10. 9by-3AP CityP4 % Zip 17✓1"f Lic#���Phone#��p�3�—�'�� <br /> Consultant/Sub Cntr �1{h f Ybkjoo� ddress CitytL4.�j�Lic#�$LPhone# 91'0 6LV-1W <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ' NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> a SOIL BORING# OVER-BORE. DIAMETER <br /> AWELL# KW 1 PRESSURE GROUT <br /> a*Other o GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS n <br /> AONITORING XHOLLOW STEM DIA.OF BOREHOLE q Q MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESSJ41�w(-TYPE OF CASING: a STEEL %PVC a OTHER: <br /> Q VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ;R�AUGERS a HOSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes ,IRNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING o HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER: 0 OTHER APPROX.BORING DEPTH a BOLTED 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 /> 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 x �ia� L ��J Title/Company <br /> t\_ " / <br /> Print Name �Y lFi�( `!1t i ��(� Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date <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 /> S R# <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 />