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San Joaquin County <br /> a. a <br /> Environmental Health Department SITE <br /> w =� 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 /> �R P 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 /> 5/ W F Assessors T <br /> WELL Location r lCIA.Lo.4/�-- - Cross Street <br /> PROPE�71' �/� /� (l (� 7 �� I /'' l �L� q��, �7� � �l: <br /> Owner lJ) (Jpi4�GG{�L(/ � ( /LUM tGYCVAddressoy-16t44A0?r..l'�1 Cdy310( k JL ZIpPhone# �-+�7 7[a0 7 �7� � <br /> C57 Contractor �L( ; Address City p ZipNZ0Lic* .7hone — 252) <br /> Consultant / SubCntr Address A&V Cit6b " VUc# 6L1VZ7Phone# O 7 /O06j <br /> GIS Coordinates: X , Y., Township Range Section <br /> WORK TO BE PERFORMED: <br /> IEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') Q DESTRUCTION (choose type below) <br /> Q SOIL BORING # Q OVER-BORE. DIAMETER <br /> .WELL # VAAe Q PRESSURE GROUT <br /> Q *Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPE IFICATIONS <br /> All <br /> MONITORING 0LLOW STEM DIA. OF BOREHOLE p Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL EVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL 1/ 0 TREMIE TYPE TO BE USED: JFAUGERS Q HOSE <br /> Q AIR SPARGE/ OZONE Q PUSH POINT (GP or CPT) GROUT SEAL PUMPED: a �YYIIIe�ss.... ,�I. ^No (NOTE: MAXIMUM REE-fA L DEPTH IS�/j,30') <br /> Q SOIL BORING QHAND AUGER GROUT SPECIFICATIONS{7d�.Q! !S$G(� 14 g�'� /0 Lij (SAL <br /> Q OTHER: Q OTHER APPROX. BORING DEPTH OLTED TRAFFIC BOX or Q 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 /> 43 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 /> COU <br /> Ordinances, Rules and Re ulations, and ail applicable California State Laws. <br /> Signed x A ,/t AA ^^ TiOe/Company 1 <br /> Print Name A �� � ty tt-F. Date Z 0 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: / ry <br /> Application Accepted By 1 +' ' V Date Issued : r �t/ , Area <br /> Grout Inspection By I f 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 /> 3J 01 $ 11 . 00 . 1 98ho 7/10/d � SR# <br /> C-57_ WC -WAIVER_ C-57 Letter of Authoriz Ion o sign permit_ Encroachment doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />