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n Joaquin County <br /> z <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: vvww.sjgov.org/ehd UNIT IV <br /> ;FOR 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 StandardsofSan Joaquin County Environmental Health Department Assessors <br /> 7S0( I�QVY Driy( Cross Street IAf y�t,OII �.City 5VO�+P, Zip IS-103 Parcel#�6Z'03d <br /> WELL Location -- <br /> 5uPPolL-T TiC9-A\IJhL3 O f(AA11116 LP " <br /> PROPERTY citySACra•r +tAba z1p9581 Phone# <br /> OwnerCone[O P6,IIitS C��, S - 609 <br /> 6 �Address BroacwR�t <br /> yy 1 qS} 6Li �Z Phone#5.30668-ZI2y <br /> C-57 ContractorRSL brll`tAra Address220 A . EaS� Sirec,+ CityW-"t1 0a Zip <br /> Consultant/Sub Cntr FyAk is k�..f rtL Address6RS Rl'Vl`OaLS ��`�'� City,SacSO�LIC# f0113R Phone#q06p"2.32.-Z.g0O <br /> 1 i, r p" T LAI Range ?,(PF- Section <br /> GIS Coordinates:X 3�o 5� 00 .Y 121°,za 3 ,Township <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') OVER-BORE.I DIAMETER <br /> ( se type below) <br /> 0 SOIL BORING,1 0 PRESSURE GROUT <br /> "LL P GROUT SPECIFICATIONS <br /> 0`Other <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> (]MONITORING HOLLOW STEM DIA.OF BOREHOLE__EL 0 MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA:_Z <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS Sck. 40 TYPE OF CASING: 0 STEEL j1pVC 0 OTHER: <br /> []VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL--:R-- <br /> TREMIE TYPE TO BE USED: [AUGERS HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATION BOR DEPTH-� tlAe� Ccs e8 LIED SRAF BC OX'otr Q S OVE PIPE <br /> 0 OTHER: 0 OTHER A <br /> CONDUCTOR CASING PROPOSED_No (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 Ordi n34X7777��Title/Companylxsk <br /> d ll alicable California State Laws. �r ,�c <br /> Martxjlr�S�atf GL0l44ts+ t'I3" �!'c <br /> Signed x �/vv�� �/- <br /> ;� p Date �7—r 0 T <br /> Print Name 'JOl fijlRCl� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: 06 <br /> Date Issued_'Ira? p 7 Area qR�_ <br /> Application Accepted By 14* Date <br /> Grout Inspection By ^•° Date���/ �"1 Final Inspection By <br /> i <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: • w <br /> ACCOUNTING ONLY: AID# tFAC#PECODES FEEINFO AMOUNTREMITTED CHECK# BY DATE PERMIT/SERVICE REQUESTINVOICE <br /> g�fo f $Ii- F - X123 �� SR# 00 0 Z <br /> C-57 WC=WAIVER,_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />