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E COPY <br /> -jan Joaquin County <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: www.sjgov.org/ehd <br /> UNIT IV <br /> 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 /> I - ^ . Assessors <br /> WELL LocationUQ rteiArI(I 0,1Mn Cross Street eS ityF�PGtCgQip I q <br /> PROPERT <br /> Owner—/ (D r min r i5 <br /> Address '71 fJ ea le S+om] City s,r. Zip l one# 4415-173- 1294q <br /> �7 Contractor /.Z 'C7Gt� (/Y3te�C74ddneT �/o�*/t(s��i�City Zip Lic# Phone# <br /> Consultant/Sub Cntr S CCS Address .�D I l k6l'916/�' R ity 1'aC Of r ffic# Phone# <br /> -r GIS Coordinates:X Y ,Township 1 5 Range C—, Section <br /> WORK TO BE PERFORMED: <br /> U NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> a SOIL BORING# a OVER-BORE. DIAMETER <br /> ELL# 1 i _ tv S` G PRESSURE GROUT <br /> Other /+ .L/ /"Y 11 GROUT SPECIFICATIONS <br /> COMMENTS: -06 Pni e 6 A 5-r !de-a-1/d/! <br /> TYPE OF WELL 4fir INSTALLATION TYPE ' CONSTRUCTION SPECIFICATIONS n <br /> a MONITORING Q HOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION O AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL O PVC D OTHER: <br /> a VAPOR 1]MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS a HOSE <br /> fIR SPAR /OZONE GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> HAND AUGERGROUT SPECIFICATIONSHER: CIO APPROX.BORING DEPTH a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> / / CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTs. 44a N01 it uj ee &t 1-4CAS -+A F iJc-IC-eed be S <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 t is application and that the work will be done in accordance with San Joaquin <br /> County Ordi nces F3#les and Reg tions, and all applicable Californi/a�Statue Laws. <br /> Signed x /� Title/Company /'� A )0. © <br /> ?. n�g <br /> Print Name Co A✓2 l�_(4q� (t r Date / 2 `� !� <br /> v <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: 'v$ P -- <br /> Application Accepted By Date Issued s Area a <br /> Grout Inspection By Date Final Inspection By e <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 /> zoo r 6bA &q /WESR# eo4es <br /> C-57-4k WC - AIVER_ C-57 Letter of Authorization to sign permit*Encroachment doc_ <br /> EHD 29-02-001 I G/94-s <br /> 6/22/04 <br /> No Co,-51 <br />