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San Joaquin County - <br /> z: .•. ? Environmental Health Department SITE <br /> 640 E. Main Street, Stockton, CA 95202-30o <br /> �. MITIGATION <br /> (209) 468-3449 Fax: (209)468-3433 Web: www.sjgo org/ehd JQOl UNIT IV <br /> 'L oWell Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISS \Vlu. <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install the work described' ion 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 /> tasZO Assessors <br /> WELL Location I, 70 U' 1`I4v�%,'*t" �a�L{ Cross Street 8"-At wGA'A QaCity 54u k Zip ! R Parcel# <br /> PROPERTY - <br /> Owner <br /> ROPERTY -z �h�v � <br /> Owner �tuwS-�n N.YAL Address �4 �Q 44- City 4oL! -v, Zip 95'D7Phone4iDq`41 V`III& <br /> C-57 CDntractor V001W"IJ "L1(' Address y" �:�r AW4 CitykO ii`�k Zip`k"l Lic# �10071 Phone# I -37y-40D <br /> Consultant/Sub Cntr x +4 5 Address 3�3J t: wklll" PA D+, City CAMt/'`�°i ' Lic# Phone# <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> JkNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) '` n DESTRUCTION (choose type below) <br /> 0 SOIL BOR G# I]OVER-BORE. DIAMETER <br /> )U'WELL#/'kW I D n PRESSURE GROUT <br /> 'Pother GROUT SPECIFICATIONS <br /> COMMENTS: -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ,' li <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE�� 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS Sc4 W TYPE OF CASING: 0 STEEL KPVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 20 TREMIE TYPE TO BE USED: 4AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes *o (NOTE: MAXIMUM FREE-FALL DEPTH 15 30') <br /> i 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS htu� ttvNRh1' <br /> 0 OTHER:_a OTHER APPROX.BORING DEPTH 40 ,,$'eflOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED_ht7 r (if YES,list specifications in comment section) (�t <br /> COMMENTS: <br /> r <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 The done in accordance with San Joaquin <br /> i County Ordinancas. Rules and Regulations, and all applicable California State Laws. <br /> Signed Titlelcompany 4f,415 <br /> Print Name ! � �c��a'�'� Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By (Ann. cra t- Date IssuedZ b Area <br /> Grout Inspection BDate `3' b Final Inspection By Date1 I_ o� <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> iso[ �g.00 (y3Z�I �( og SR# �C�`�� <br /> _ t <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit•,Encroachment doc✓ <br /> EHD 29-02-001 web <br /> 6122/04 <br />