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n Joaquin County o �^ <br /> [FC V SITE <br /> Environmental Health Departm <br /> 600 E. Main.street, Stockton, CA 95202-3029 . 200$ . MITIGATION <br /> '.�-- (209) 46873449 Fax: (209)468-3433 Web: www"sjgov.or UNIT IV <br /> Welt Permit.Application ENVIRONN1EN i-HEALTi — <br /> PERfOITJSERVIGES <br /> NO—REFUNDABLE PERK"lT EXPIRES!YEAR FROM DATc ISSUED <br /> I' lication is made in <br /> Application is hereby made to San Joaquin County for a permit-to construct and/or instatl the work described. This app comliance with San <br /> p <br /> Joaquin County Development Title;Chapter 5-1115.3 and the Standards of San Joaquin County Environmental Health Department.Assessors <br /> WELL Location $ Vh Cross Street City zip^�5�D3 Parcel# 1�S h2a� <br /> PROPERTYq3-M&Phone# <br /> Owner. `Atfdress�n l3bX 1' 147 City FY an—Q _Zip Q�_ <br /> C-57 Contractor <br /> 1 Address_it 1 E City Ri hmnt7J zip g4&bj_Lic#-7Phone#(�3 7- 1 <br /> Consultant!Sub C ntr_mu needc-Addres s $6 4 f City s -b1 <br /> Lic# Z_Phone# 109 Cf -1 <br /> G15 Coordinates:X- <br /> Y ,Township Range . Section <br /> WORK TO BE PERFORMED: <br /> ANEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGF-k OTHER') g DESTRUCTION (choose type below', <br /> SOIL BORING# Ci}T-I _ g OVER-BORE. DIAMETER <br /> PRESSURE.GROUT <br /> ©WELL# GROUT SPECIFICATIONS <br /> 0.Other <br /> I• COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE • CONSTRUCTION SPECIFICATIONS <br /> € 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2x O.MULTIPLE.CASINGS a MULTI-LEVEL WELL CASING DIA. <br /> g EXTRACTION a AIR HAMMERIDRIVEN � CASING THICKNESS_ _ TYPE OF CASING: g STEEL 0.PVC g OTHER: ' <br /> 0 MUD ROTARY " DEPTH OF GROUT SEAL a5j TREMIE TYPE TO BE USED:. 0 AUGERS g HOSE <br /> 0 VAPOR <br /> t 0 AIR SPARGE!OZONE -`PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes jrNo.(NOTE: MAXIMUM FREE-FALL"DEPTH IS 3D') <br /> "f %SOIL BORING g HAND AUGER, GROUT SPECIFICATIONS T s 'R64)and <br /> 5 0 BOLTED TRAFF <br /> APPROX.BORING DEPTH L IC BOX or 0 STOVE PIPE <br /> 0 OTHER: 0 OTHER -- --' . , <br /> j CONDUCTOR CASING PROPOSED NO (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 /> 1 hereby certify. that I have prepared this application and that the work will be done in accordance with'San Joaquin <br /> 1 County Ord' aces Rul nd Regula ons, and all applicable California State Laws. <br /> i <br /> Signed x TitlelGompany `P►'P�iGI Int <br /> s <br /> Print Name M Y? , V Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> { <br /> WORK PLAN DATED: Za <br /> Application Accepted By Date Issued S 0 Area-7 _ <br /> Grout Inspection By Date Z 19Final lnspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS! D <br /> ACCOUNTING ONLY: AID# #FAC#PECODES FEE INFO AMOUNT REMITTED CHECK# .DATE' -. PERMIT!SERVICE REQUEST# INVOICE <br /> �90� <br /> C-57_ WCC WAIVER. 'C-57 Letter of Authorization to Sign permit—Encroachment doc_ <br /> Ic EHD 29-02-001web <br /> y 6122104 <br /> 363 may_ 2-� <br />