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ole.Vfty � � San Joaquin County <br /> q% Environmental Health Department ! .!' _i 81TE <br /> y: { 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> ' 209 468-3449 Fax: 209 468-3433 Web: www.s ov.or /ehd lllia <br /> > > �g g �� - �f UNIT IV <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 /> q ( f I ��"1 G� Assessors <br /> WELL Location S t I ! F s&-eg-T Cross Street 5A f lit City V TC Zip �i L Parcel# <br /> PROPERTY- Q �, ` .�/ ?� <br /> Owner L�(){// mpO(2— /Addj�ryyess A 1� � S�7\iiCCC�� City �nTZL Zip`` hone# L-�J �J J �q�J� <br /> C-57Contractorh� (�L£; TT�'I'� la'Address1 l�,Q�pX �b City tC �Iu Zip 7 Lic# Phone# 3 `f�{3�0 <br /> Consultant/Sub Cntr 'c AVW " Address jf l,� City A"Lic# iUokg Phone#6&2?S(-'0)'94 <br /> GIS Coordinates:X rr ' 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ffiNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> a SOIL BORING# a OVER-BORE. DIAMETER _ <br /> WELL# a PRESSURE GROUT <br /> *Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS n <br /> 'MONITORING HOLLOW STEM DIA.OF BOREHOLE g1� []MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: 2- <br /> a <br /> o EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS-'. 0 TYPE OF CASING: 0 STEEL 4g WVC 0 OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: iKAUGERS a HOSE <br /> Q AIR SPARGE/OZONE [I PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes -,JTNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> a SOIL BORING o HAND AUGER GROUT SPECIFICATIONS <br /> o OTHER: 0 OTHER APPROX.BORING DEPTH a BOLTED TRAFFIC BOX or p 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 tannd Regulations, and all applicable California State Laws. /� / <br /> Signed x ff (�12/ l,t� Title/Company <J*tl'�f�(�d�Cc_w �'�[fl1i�/X' ✓�YOtCr t,�Ix. <br /> Print Name CN� l ` lG �� Date 1�~ ( � <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: z —6 <7 <br /> Application Accepted By JvvG� �w-JQ_�cv� Date Issued lCJ la�% J� Area <br /> Grout Inspection By A14011 Date O .l O Final Inspection By C// Date AD / O <br /> Destruction Inspection By Da(e <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# /REC'D BY DATE PERMIT <br /> //SERVICE <br /> �REQUESTST# INVOICE <br /> �'c �/n <br /> Or C2G'd2 C.1,r, � SR# V'Q /I L.l 5-/V <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> 6 222/04 02-001 3 Sv 3 '-4've'Q 10/3 114s— <br />