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��QrN San Joaquin County <br /> /? ` o Environmental Health Department SITE <br /> X 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209) 468-3449 Fax: (209) 468-3433 Web: www.sigov.org/ehd UNIT IV <br /> 0¢ 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 9-11116.!3 and the Standards of San Joaquin County Environmental Health Department. �A <br /> Assess <br /> WELL Location CG S W �J I}I-111AT �'f Crass Street LI kA �T City ,Zip 9(2m— arcel#rs�97"?14 '- 11 <br /> PROPEgbI i�. LCa / R/ �'fj335TarI i iP <J � <br /> Owner(f ) LA <br /> Address rlt ( City 21p Phone# -a'! 96� - �67 <br /> C-57 Contractor ,/ �� / Nl-/ Address fd�O�A /rl///4Z'ZB Wy City Q Zip ? 10 LLi7�Phone 1? <br /> Consultant / Sub CnlrAbtd YlJ j/ Address&,,s#W &Q/ (2 City ,�{[Ljc* nD '12Z Phone# 2y03 - D�p <br /> GIS Coordinates: X., Y., Township Range Section <br /> WORK TO BE PERFORMED: <br /> )(NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER•) 8 DESTRUCTION (choose type below) <br /> aSOIL BORING # _ II OVER-BORE. DIAMETER <br /> rUL * A lge ,,,¢, p ti [ 1] PRESSURE GROUT <br /> her GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING >LHOLLOW STEM DIA. OF BOREHOLE, Z a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: Z <br /> EXTRACTION nAIRHAMMERIDRIVEN CASING THICKNESS LIi�P TYPE OF CASING: fl STEEL VPVC U OTHER: <br /> O VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 'i. F1 TREMIE TYPE TO BE USED: ,)' AUGERS a HOSE <br /> a AIR SPARGE/ OZONE a PUSH POINT (GP or CPT) GROUT SEAL PUMPED: a Yes ,0o (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> O SOIL BORING - a HAND AUGER GROUT SPECIFICATIONS �'fi-' Ail eeinenj ' _ /p7ft* A 6{ QUA <br /> 0 OTHER:.n OTHER APPROX. BORING DEPTH ZS C gtBOLTED TRAFFIC BOX or n 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 andd Regulations, <br /> 'Iand <br /> , all applicable California State Laws. <br /> Signed x� GLX �LJ� Title/Company_ 1 <br /> •' <br /> � � <br /> Print Name i ) AAIT: P L VALVIAAC { Date 7- V <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : <br /> WORK PLAN DATED: �v <br /> Application Accepted By Cc "✓ Date Issued /o "'✓ rea <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 ] CHECK # REC'D BY) DATE PERMIT / SERVICE REQUEST # INVOICE <br /> 00 2Zoq < 3 N { o pq SR# 3 68 <br /> C-57_ WC_-WAIVER_ C-57 Letter of Autho atio sign permit_ Encroachment doc_ <br /> EHD 29-02-001 <br /> 6k2/04 <br />