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j San Joaquin County <br /> r' °yam Enviesmental Health Departments SITE. <br /> y { 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 /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM D J PM 2;.07 <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 Count} ly#oj-kM l I a�lrplent. <br /> NI`9� 3 Assessors <br /> WELL Location �b S l �tl}�6� 5� Cross Street Y ! °"C ity �Parc2, d �J <br /> PROPERTY � "} Q�`�,�/ C � ,i l� '�} <br /> Owner Address5 11 `"a �" V– f Cva V,City +Y Iv Zip[�t'��Phone# t�l�`0 �� + <br /> C-57 Contractor Circ AddressI O MMIC _ City R"& Zip+� Nti -Lic# j C5LC7Phone#91b-b1a� <br /> Consultant I Sub CntrAt' Address D'3-1 S CitSkic `n Lic#�Phone# t006 r_ <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER*) p DESTRUCTION (choose'type below) <br /> p SOIL BORING# 0 OVER-BORE. DIAMETER <br /> LL# 111f" _ 0 PRESSURE GROUT ti <br /> *Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> )LAONITORING 'HOLLOW STEM DIA.OF BOREHOLE it <br /> 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING QIA: <br /> 0 EXTRACTION <br /> 0 AIR HAMMER1DRlVEN CASING THICKNESS a TYPE OF CASING: 0 STEEL )(PVC'� 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL t( TREMIE TYPE TO BE USED: JfAUGERS 0 HOSE <br /> 0 AIR SPARGEI OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS ?b1(1kQ.K4 <br /> 0 OTHER: 0 OTHER APPROX. BORING DEPTH XBOLTED TRAFFIC BOX or 0,STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) j <br /> COMMENTS: <br /> NOTE:. OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I h ve prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi nes, u s an egg s, and all applicable California State Laws. <br /> _ <br /> Signed x Title/Company <br /> Print Name Y l Date 1 — 05 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED-: <br /> Application Accepted B Z3., Date Issued 111611 Z/G� _Area <br /> 0 <br /> Grout Inspection By to Final Inspection By Date <br /> DestructionInspection B Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> C-57 WC -WAIVER C-57 Letter of Authorizto sign permit Encroachment docs <br /> EHD 29-02-001 <br /> 6122/04 <br />