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,r:4.�.!ti � �.1"iG S®a�GEFFTG.4�C➢rFt�' �,j .. - —_ <br /> 0 <br /> Environmental Health Department SITE <br /> <i 600 E. Main street, Stockton, CA 95202-3029 MITIGATION <br /> 77 (209) 468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> cy. . <br /> Well Permit Application <br /> - - NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 County Environmental Health Department. <br /> f _ Assessors ;G —7 '7 <br /> WELL Location ' oY� �` `'r •' ( Cross Street I'�:X �:-. s(-,City ;%`^'I"`�" Zip'1 ti?3ii Parcel# <br /> PROPERTY .a <br /> Owner - 11`1 "•'-^"^ Address (r i' "'r "" City 'ter"F Zip 3; Phone# <br /> C-57 Contractor 'w...Ayr..:cl 1. ,i•h;1 Address '.Syr 'r'-r :'�� -a. CityZip Lic#' �".. Phone# <br /> Consultant/Sub Cntr �'Address dsl6 "'•^Z' n !�"r" i� City-- <.'ox Lic# Phone#r"-_' - <br /> r'-r 4 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> [] NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') gDESTRUCTION (choose type below) <br /> []SOIL BORING# .[COVER-BORE. DIAMETER Xk C�✓-'r <br /> []WELL# O PRESSURE GROUT <br /> []`OtherGROUT SPECIFICATIONS <br /> COMMENTS: ('�?tIS /fq:.rI ,4'1 W_} �. ✓!b'- +Nt t✓-i: 1 _`_� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_ a MULTIPLE CASINGS [I MULTI-LEVEL WELL CASING DIA: <br /> [I EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL U PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: [i AUGERS 0 HOSE <br /> []AIR SPARGE/OZONE [I 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 <br /> 0 <br /> OTHER:_0 OTHER APPROX.BORING DEPTH n BOLTED TRAFFIC BOX or []STOVEPIPE <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 /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed xe�-Zf&A Title/Company S41,�+("L1 C n✓.Y'cl :✓•n ,%n L, <br /> Print Name 17111111, :J 4ry;�G�:��r Date CM/0,>, <br /> DEPARTMENT USE ONLY, <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: /V �4- <br /> Application Accepted By > Date Issued / I / Area <br /> Grout Inspection By U Date Final <br /> Inspection By Date <br /> Destruction Inspection By ,11 ° lt• E'l.L� Date <br /> �T <br /> COMMENTS CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE NFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3503 375 <br /> -1 ,3-;1,5- aa� 3 � lis 65 SR# 57j <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EH 29-02-001 web <br /> 6/22/04 <br />