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a-� = DI s �iUFILE <br /> COPY <br /> P an Joaquin County <br /> Q % Environmental Health Department SITE <br /> 600 E. Main Street, Stockton,CA 95202-3029 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov .org/ehd UNIT IV <br /> �'1��FORN`P Well Permit Application ' . <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED wb, � ft,5 <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 Devel pment Title Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department, <br /> 4'�� �1 /' L !' Assessors <br /> WELL Location a�'/ >;� �. ti/Q Lit! A�Pww CCross Street l `Ute City$ -49 "✓ Zipy Sa;7 } Parcel# Avl I <br /> PROPERTY- <br /> Owner <br /> ROPERTYOwner C!ty o-F S fiak"04dress�/ o�1 N fl De.✓e City Cj¢ickfiaw Zip1Fs aPhone# g37 - gf 5/ 9' <br /> C-57 Contractor 10 r fcrsmo 57.t&;41 rens a �. �✓r^ w 0, City 57%1okf-.Zip fdo ic# MX_JFP�hone o 6 <br /> Consultant/Sub CnlrjNt Se wr CC 6tvW.0 Address 7YY a •. . -City& �."Va4f Phone#(�i•O <br /> IN <br /> GIS Coordinates:X��,Y —12-1. V5 Township Range Section <br /> WORK TO BE PERFORMED: <br /> n NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*)' DESTRUCTION (choose type below) <br /> 0 SOIL BORING# g OVER-BORE. DIAMETER <br /> 0 WELL# PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS ^� <br /> COMMENTS: Al W' 015 - 195 M W- 0I5 —S.D <br /> C <br /> t TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> d 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_ a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION n AIR HAMMER/DRIVEN CASING THICKNESS TYP1.E OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> - 0 VAPOR n MUD ROTARY DEPTH OF GROUT SEAL !i TREMIE TYPE 1-0 BE USED: GAUGERS g HOSE <br /> a AIR SPARGE/OZONE n PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes n No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> n SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 11 <br /> a OTHER:_0 OTHER APPROX.BORING DEPTH a BOLTED TRAFFIC BOX or 0 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. r <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' ces, Rules and Regulations, and all applicable California State Laws. <br /> r c+ <br /> 16 - G <br /> Signed 1 Title/Company1. <br /> _ 5 <br /> Print Name /Z V 1 t Dale a 9 �� o <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: 2"o/G <br /> Application Accepted By Date Issue J Area <br /> Grout Inspection By Date - Final InspectionEBy 7 _�" Date /V <br /> Destruction Inspection By Dae <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# b <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE'.! PERMIT I SERVICE REQUEST# INVOICE <br /> 3'502,- <br /> SR# (pQ3�0 <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign pe rmitD�_Encroachrnent COPY <br /> EHD29-02-001web f .N <br /> 6/22/04 <br />