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o,a"'N San Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,'CA 95202 MITIGATION <br /> (209)468-3449 Fax: 209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> \9 } <br /> Foal Well Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County fora 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 S Joaquin County Environmental Health Department. _ <br /> WELL Cocatlo � /Q m+d'Qr 411 Cross <br /> Street i City .�/ 44!� i.p #r�'G- 2 <br /> 5, <br /> PROP T`+ LSC ,(fp /�` �— -g <br /> Owner Address LO Q-� �h� C ity.? . .1N 3ip7�o/shone# <br /> C-57 Contractor i y ddress J + _City �ip JZ�c# Phone#p�[�5 <br /> Z <br /> Consultant/Sub Cntr ne AddrLess _ CitX�—Lic# - - Phone# <br /> GIS Coordinates:X Y SIN.2✓S Township - Range Section - <br /> WORK TO BE PERFORMED: <br /> D NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION (choose type below) <br /> SOIL BORING# D OVER-BORE. DIAMETER _ <br /> 0 WELL# V&RESSURE GROUT <br /> a*Other ''/ GROUT SPECIFICATIONS <br /> � Sa-C_te— <br /> COMMENTS: y(/ • <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECI!7 ATp IONS I r <br /> �v10NITORING 0 HOLLOW STEM DIA.OF BOREHOLE D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS A 40 TYPE OF CASING: D STEEL , PVC 0 OTHER: <br /> D VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: []AUGERS D HOSE <br /> D AIR SPARGE/OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING D HAND AUGER GROUT SPECIFICATIONS 5 *rt ck" <br /> 0 OTHER:_0 OTHER APPROXI BORING DEPTH !It-" D BOLTED TRAFFIC BOX or D STOVE PIPE <br /> (.- CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS:/VtcJ S —G - <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 Ordi lances, Rules a egulations,and all applicable California State Laws. <br /> Signed x .ter/ Title/Company 7�C(YTh*fid <br /> Print Name Yi /i• i Date <br /> rlti DEPARTMENT USE 9NLY GO� <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 11 V N- � <br /> WORK PLAN DATED: <br /> Application Accepted By - _ Date Issued - Ar 1 <br /> Grout Inspection By3 Date Final Inspection �O ate <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK.# RECD BY DATE PERMIT I SERVICE REQUEST 0 INVOICE <br /> oy Vv 60,� r3 zo (.234 sR# g � <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 1 <br /> EHD 29-02-00) <br /> 6/22/04 <br />