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c,An Joaquin County <br /> it <br /> Envirot--mental 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 UNIT IV <br /> Lf GQ? Well Permit Application <br /> � Atn1 0 .� <br /> N REFIIUNDABLE PERMIT EXPIRES745AR'FROfvf DATE I�SLIED <br /> Application is hereby made to San Joaquin County for a permit to construct an�/grkst"l pf@,69R 0"ibba YThis application is made in compliance with San <br /> Joaquin County Developmen Title,Chapter 9-1115.3 and the Standards of SaT13'riaS&�Ip. ItIyWrNifoArLental Health Department. <br /> MMg r ;Sra�x T p 7 n/J Assessors <br /> WELL Location�_ Cross Street Cit Zi(flParcel# / q$2.D 13 <br /> OwnerPROPT'/fit/✓• ++ddres�*/" �LUI /+ Zip`F�`�i0ne# {!J— ) <br /> C-57 Contracto Add re '-��it�"acIc#7_ IAone#q �0// <br /> Consultant/Sub Cntr�� Address c�iT CI� lulit�j� Phone# 7 /0( ) <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> Q NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER') Q DESTRUCTION (choose type below) <br /> Q SOIL BORING# Q OVER-BORE. DIAMETER <br /> Q WELL# Q PRESSURE GROUT <br /> Q`Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATI NS Jm <br /> ONITORING HOLLOW STEM <br /> MkDIA.OF BOREHOL ntLTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> TRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS 71y TYPE OF CASING: Q STEEL F'PVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL� TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> Q AIR SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes Q, Ngo/(NO 1TJE MAXIMUM FREE-FALL DEPTH IS 301) <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS�K '1ra��C- <br /> Q OTHER: Q OTHER APPROX.BORING DEPTH BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> t Well_r <br /> CASING PROPOSED (if YES, list specifications in comment section) <br /> COMMENTS: ja L� We'1 C <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, Ruul/Ie77��s�r(a8/�n�n�td Regulations, and all applicable California/State Laws. <br /> , / <br /> Signed x /y(�L�Ll�.f�[ildF'//[�.�� Title/Company C..7�< "�I�s� —5,14`-2� <br /> Print Name /4 l/Z�Aa �/T/v Date LV � <br /> DEPARTMENT USES ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 3D�* S'f <br /> WORK PLAN DATED: $e—j2+e.mb" z5020o5- 1 <br /> Application Accepted By V i c+ey;n L. M,_�iJ r+nmq Date Issued l0 Jf-2 r] ' O r! Area )4s-f <br /> Grout Inspection By Jo-e�64wgftdldgZe`t Date A- - US Final Inspection By (rTdr'a L�r�Date !/-Z.-OS <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: I B E W` <br /> rACCOUNTING ONLY: AID# FAC# <br /> DES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> i79 36S.o0 sR# 4455 <br /> C-57_ WC WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br /> EHD 29-02-001 <br /> 622/04 <br />