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P0." man Joaquin County <br /> Environmental Health Department SITE <br /> Q: a <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> c p'� (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> a�rF°Rai Well Permit Application gnSEP - Q 10 49 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE�SSUED ""k-f'{ <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work de$S*b�.-; i*i ade in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environn'6M.4 1`e��rt(r�QrdNT <br /> r <br /> BEALT Assessors <br /> WELL Location 2q�tl ��� V Cross Street Lj,t,m City �40„�4c� Zip SZD(� Parcel# N b to <br /> PROPER <br /> o <br /> Owner ,k � F SAddress Sft CityZip `1SZ�S Phone# Z0�1•`t�t6,0ZLq,6 <br /> C-57 Contractor �­A;Ju,Address Air, City S� Zip LLic# 8 Phone# sb4-t Zo <br /> Consultant/Sub Cntr Q,su Ct- ,L �� Address c\6vSSZ) talk„ 11iJa City Lic# \b9E61} Phone# 5��"t2�1 .L1--fit <br /> GIS Coordinates:X ro31_2-0 57-- 'Y 6i., 03 Township 1N 3 Range Section I� M <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> &WELL# 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0.MONITORING SHOLLOW STEM DIA.OF BOREHOLE S` AMULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:_Z _ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS Sj,,t-tC TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL -- t 3 L14 ' TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes gNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Q"A C� <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 71.1N k C 5s .BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED JA'`(FS (if YES,list specifications in comment section) <br /> COMMENTS: 0cJk elk-1 Z'd CC4,t o.-- <br /> C+,,,(l�,.tt,4� - W•'l CaS ..�J..l. c...l.t.�_ esti- o cl.cc..�Yi,v -Jc.C.:.s SS',. <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 Ord' ances, Rules and Regulations, and all applicable California State Laws. /1 <br /> Signed x R (� Title/Company I 1 1st ctl l.e AS�c'_ . S <br /> Print Name o-- Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: q /Ih - <br /> Application Accepted By. Date Issued //f/ y� Area <br /> Grout Inspection By !'' Date EP 12110 <br /> Final Inspection By Date <br /> Destruction Inspection By Dat <br /> COMMENTS/CONDITIONS: 57'7( �GtJr2t� � S <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 4L SR#00 1� <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 />