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ul San Joaquin County FILE COPT <br /> r�� o�i Environmental Health Department �P- p5 SITE <br /> M K 304 East Weber Avenue, 3rd Floor,Stockton, CA 95 2 d�j�(?i� ITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.Or /ehd l� UNIT IV <br /> crFo>: Well Permit Application f� <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED C) ` ` .D• <br /> Application is hereby made to San Joaquin County for a pennit 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 County Environmental Health Department. <br /> I Assessors <br /> WELL LocatiorZSuG=W.W� '��'�7y ' S-Cross Street,- unity7� _Zip .Assessors <br /> PR <br /> Ow ,f �L9'� 6Agco51 <br /> OwnerY ((TI'S ,• v,, A,ddress V� r CityyS q�-jO/j Zip r_U Ph,nne## <br /> C-57 Contracto*( , yp1irl1�{o(QJtY Address ,, 11 1� y-CitXy Zip 1-ict7Jl2_2KPhone '� <br /> Consultant/Sub Cntrr(l�A RJ 0.w/�Cn- Address�C✓ t,1 W C/t.,` r: (0)City 0 Lic# G Phone# <br /> GIS Coordinates: <br /> (�X,��y"JZ�2�S11�bci�.J(� ,Y /.lU-�f, Rl ,Township 01� Range 0Q F-_ Section_ <br /> WORKTOBEPERFORU-9:l I/ 1L-/r Lam: S SIO( 3l/-KIu <br /> %NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> 0 SOIL BORING#W 0 OVER-BORE. DIAMETER <br /> ELL# f�.�. —(Q> 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLEJU]V 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 400 TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL O`5 TREMIE TYPE TO BE USED: [AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes ANo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS� / G td'� r uyY f'*� <br /> 0 OTHER: (1 OTHER APPROX.BORING DEPTH G.G. �*OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSEDK)4) (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 that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules a d Regulations, and all applicable California State Laws. <br /> Signed xU�.Ul�UY I IN-- Title/Company CAi <br /> UIP <br /> Print Name ,'(,XA_��'S/l� Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ZS llj. Zq'� \Y <br /> kIL <br /> WORK PLAN DATED: 3 ZooAAu�P, e <br /> Application Accepted By Date Issued 6—2.3-CY6 Area C6 oi.A-- <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 290 MW gj gZ �i (o-� SR#Q <br /> C-57--,/ WC -WAIVER_ C-57 Letter of Authorization to sign permit_En _)e c��M�ennt doc_. <br /> EHD 29-02-001 a4e_� -�� <br /> 6/22/04 <br />