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'I <br /> u ' " San Joaquin County <br /> tQ ti Environmental Health Department SITE <br /> Iw; < 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209) 468-3449 Fax: (209) 468-3433 Web: www.sigov.org/chd UNIT IV <br /> Faa 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 /> WELL Location 5�/7 yy —f1dDT STr Cross Street � fD1AKCity 5/0, kb") ZpSAssessors 7 <br /> PROPEFTY _ /r /� /7 I� c- <br /> Owner ( /LtX�WAL/!/WHOA S[ / I lieh w J� h,i � _, p (7/V�� 96,-6-_�_67�f; <br /> dI KA <br /> r Ci r Zi PhoneVY <br /> 1 S 1•I'lA Z3' alA nn, t t q <br /> C-57 Contracto Address Cit ! "PhoneO.W ap F�� <br /> I 'kConsultant / Sub Cnfr .E Address 0 <br /> 5iw City, �( Lic# Phone#aVj67- o <br /> GIS Coordinates: X., Y., Township Range Section <br /> WORK TO BE PERFORMED: <br /> XNEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') 11 DESTRUCTION (choose type below) <br /> D SOIL BORING # U OVER-BORE. DIAMETER <br /> a WELL # 0 PRESSURE GROUT <br /> Other ,arrIr\4 — A — A GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING a HOLLOW STEM DIA. OF BOREHOLE_2,�l U MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIN A <br /> U EXTRACTION 3 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL n, TREMIE TYPE TO BE USED: YAUGERS a HOSE <br /> 0 AIR SPARGE/ OZONE `PUSH POINT (GP or CPT)GROUT SEAL PUMPED: Wes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING aHAND AUGER GROUT SPECIFICATIONS <br /> a OTHER:.0 OTHER APPROX. BORING DEPTH' Fjn Z p BOLTED TRAFFIC BOX or O STOVE PIPE <br /> CONDUCTOR CASING PROPOSED AtV (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 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> CouPAILOrdinances, Rules and Regulations, . d all applicable California State Laws, <br /> Signed Title/Company (="' .If vr' <br /> Print Name AtJ1: F. I LZALM &AC14 Date Z D <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : <br /> WORK PLAN DATED: <br /> Application Accepted By ` , - ` Date Issued 7 to , C-ll� 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 /> OI �� , � � Z� gJr J// 1) /0SR# q <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorize ion o sign permit_ Encroachment doc_ <br /> EHD 29-02-001 <br /> 6!'12/04 <br />