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• - • FILE COPY <br /> San Joaquin County <br /> 2 i Environmental Health Department n_ SITE <br /> w iG�T <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 JJ MITIGATION <br /> Well Permit Applic��iron <br /> (209)468-3449 Fax: (209) 468-3433 WeV�o#r}Aggy or ehd UNIT IV <br /> OcrFo'R°vP .JJUUttVV ff M II: 24' <br /> N jo,�uu;r.I (�auNry <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR F�a'1'+gA`�t iWGOr A L <br /> Application is hereby made to San Joaquin County for a permit to construct and/or insta r Wesir&R.Ittl�(4��lication 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 /> Assessors (( <br /> WELL Location Cross Street cQ�� city At Zip Parcel# <br /> PROPER 64:: - / <br /> Owner dress 43 44U I Lf+ 1004 City �4+ 1 Phoyyne# It q4 —I1 L� <br /> C-57 Contractor nll•w( Address r♦♦1-V )L4a. 9- city <br /> A fpcz Zi'�I�pLidpt� Phone# <br /> Consultant/Sub Cntr (!r'1� �af 1 yI( U.A OM1y�—kic# I�4 Phone# i t-- 7 <br /> t !o <br /> GIS Coordinates:X ,Y ,Township �' V <br /> Range Section_Z( <br /> WORK TO BE PERFORMED: <br /> V EW WELL/BORING CP EOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> O SOIL BORING# O OVER-BORE. DIAMETER <br /> O WELL# O PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> O MONITORING O HOLLOW STEM DIA.OF BOREHOLE_ O MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA: _ <br /> O EXTRACTION O AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: O STEEL O PVC O OTHER: <br /> O VAPOR O MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: O AUGERS O HOSE <br /> O AIR SPARGE/OZONE KUSH POINT(GP o cP GROUT SEAL PUMPED: O Yes ON (NOTE: NIAXIMUM FREE-FALL DEPTH IS 30') <br /> O � <br /> X<OIL BORING HAND AUGER GROUT SPECIFICATIONS . <br /> O OTHER:_O OTHER APPROX.BORING DEPTH�p t O BOLTED TRAFFIC BOX nr O STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (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 th�l have prepare s application and that the work will be done in accordance with San Joaquin <br /> County Ordinan s, Rules and R ons, and all applicable Californiaa State Laws. (� / <br /> Signed z Title/Company A►(' d 1 cj • "^�Stir_ di/ tLN„P <br /> Print Name pate `f Td 1 in/I(,L� <br /> DE ARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: w r BJH-w— <br /> - <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued gW. Area <br /> Grout Inspection By Date Final Inspection By Date 7-R-06 <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DA PERMIT/SERVICE REQUEST# INVOICE <br /> ?moo S It <br /> C-57_ WC WAIVER_ C-57 Letter of Authorization to sign permit_Encr c�ment docc <br /> EHD 29-02-001 <br /> 6/22/04 <br />