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Cin Joaquin County <br /> �� (� <br /> ����Elviro mental Health Department SITE <br /> 600 E. Main Street, Stockton,CA 95202-3029 MITIGATION <br /> 2 5 ?W 468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> #1RONMENT 4ALTH Well Permit Application <br /> PERU T'S[RV .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 JoaquinCountyEnvironmental Health Department. <br /> WELL Location IS I,�2 SeinlL Nw I4, Rd, Cross street Tticht le, S}.city I.4l' yp zip 95.330 ps pors 156-10D'� 7 <br /> PROPERTY 1� <br /> Owner Mr. Nk IWI•'(rr //Nasi Address (S ob SAL'I" AJ, City Lct{l,✓of Zip fWO Phona# <br /> C-57 Contractor UW„(IJuA b-1l wl Address SS11RYWr Puad City Rio Vp Zip 9US1 Lic#710ti 79 Phone# 70/-;74'43ou <br /> Consultant I Sub Cntr S 4-kl p �lssu ria-69G Geo <br /> NS eh rh h m1w 1'r.IAddresa;;TO�+m[ro n 4.k �. CiTy _�Lic# Phone# V <br /> GIS Coordinates:X .Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER*) DESTRUCTION (choose type below) <br /> a SOIL BORING# � OVER-BORE. DIAMETER 1l A C below) <br /> 0 WELL# 0 RESSURE GROUT <br /> a'Other GROUT SPECIFICATIONS <br /> COMMENTS: W{I S MVI r M W'2 Q Hd M V•3 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPEQIFICAnONS <br /> n MONITORING a HOLLOW STEM DIA.OF BOREHOLE_ a MULTIPLE CASINGS a MULTI-LEVEL WELL-CASING DIA: _ <br /> 0 EXTRACTION B AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: p STEEL 0 PVC B OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: U AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE O PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> p SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: A OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications In comment section) <br /> COMMENTS: <br /> I <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin <br /> CountyI as,Rules and Regulations,and all applicable California State Laws. <br /> Signedx� Titie/Company .rr'L 1 Cft0'Vv,'WRII �ffpll sin L. <br /> Print Name 'hy Date 6/1 SSU 1 <br /> DEPARTMENT USE ONLY <br /> J <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ISS 8�1 l YwlX4+�- o` �y+a� <br /> WORK PLAN DATED: /UNt / qCo.-pplication Accepted By Dale Issued_ 2 /Lqb 1q t <br /> f Area / <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC/ <br /> PE CODES FEE FO AMOUNT REMITTED CHECKS REC'D BY DATE PERMIT/SERVICETREQUEST INVOICE3503 3 5 3 a0$ 318 � ? IS b5 SR# 57'? <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 web <br /> 6/22/04 <br />