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vas iJr cvv.� 1Y JJ LV JYVVJY JJ rir in r�UVr� I'1-1UG GL i <br /> �� San Joaquin Countyc° Environmental Health Department SITE <br /> 304 East Weber Awelnue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> • (209)468-34. 9 Fax (209) 468-3433 Web www slgov org/ehd UNIT IV <br /> fio Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> ppLeation is hereby made to San Joaquin County for a peril to construct andfor install the work described This applscation Ls made in cempl.ance wsth San <br /> oaquin County Devetopment Tstle,Chapter 9-1115-3 and the Stsndards of San Joaquin County Environmental Health DeperunentAssessors <br /> c Zrp gS3Parcel#,z I y-02. -t <br /> WELL Location <br /> Grxtu GviEr Cross Street-�PhT •�_.a,. City <br /> 1 <br /> PROPERTY ~ 'IO"� ��^ ���SZip X16 Phone# <br /> Owner 1 ''t roetu��5 Address C'ty <br /> C-67 Contractor 'D Q ci duress C�tyll r� he zipq`1 _Lic 'jIt� L <br /> City Phone# � -4�i-Z?y�Z <br /> Consultant!Sub Gnlr G <br /> Address 2,-, Sov>Ml�- L,c# <br /> GIS Coordmates X <br /> Y Townsh p Range Section <br /> WORK OBE RFO MEDDESTRUCTION (choose type below) <br /> EW WELL.I BORING (CPT GEOI>ROBE,HYDROPUNCH HAND-AUGER, IiE ]Il OVER-BORE DIAMETER <br /> I]SOIL BORING# I]PRESSURE GROUT <br /> rg-WELL# GROUT SPECIFICATIONS <br /> R'Other <br /> COMMENTS <br /> TYPE OF WE IL INSTALLATION lYP CONST CTION SPECIFICATIONS <br /> MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA Z�f <br /> MONITORING Y,—1( <br /> STEM DIA OF BOREHOLtw„�_ ti � <br /> EXTRACTION I13 AIR HAMMERIDRIVEN CASING F GROUT <br /> `�O _TYPE OFRCASING P XSTEEL 70 BE USt•D VC U GERSOTHER V4OSE <br /> d <br /> OR p MUD ROTARY DEPTH OF GROUT SEAT! — r <br /> OR <br /> OZONE U PUSH POINT(GP or CPT)GROl3x SEAL PUMPED Yes ❑No (NOTE MAXIMUM FREE-FALk.DEPTH-IS <br /> 13 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> OTHER APPROX BORING DEPTH 2.ar� (]BOLTED TRAFFIC BOX or I]STOVE PIPE <br /> OTHER ''11`` <br /> CONDUCTOR CASING PRO POSEfl�y� ..(If YFS Inst speutications in Dominent s¢cGan <br /> COMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT <br /> FOR INSPECTPROACHMENT PERMITS. <br /> 48 WORKING FLOURS NOTICE REQUIRED <br /> 1 hereby certify that I have repared this application and that the work will be done in accordance with San Joaquin <br /> County Ordl s i and Re ons, and all applicable California State Laws <br /> 0111 <br /> Tlue/Company <br /> Signed x <br /> Rate ! .r <br /> Print Name r <br /> DEPARTMENT USE ONLY <br /> S)TE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED0� <br /> i Date Issued_ 7�N� Areae. <br /> Application Accepted By <br /> Grout lnspoction By Date Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS l CONDITIONS <br /> CCOUNTING ONLY AID# FAC# <br /> CODES FEE INFO AM <br /> REMITTED CHECK RECD Y DATE <br /> PERMIT!SERVICE REQUEST# INVOICE <br /> C-57 WC -WAIVER C-57 Letter of Authors I 9n permit Encroachment doc <br /> LLD 29 02A0 <br /> 6/27/04 <br />