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NSan Joaquin County <br /> 4 ? Environmental Health Department �� SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.orj2@0§AUG 39 AM g:lgylT IV <br /> r . P <br /> A`'xaa� Well Permit Application <br /> SAN J0AOtli?i COUNTY <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSU R-EN V IR`` N MEN T A L <br /> ALTH <br /> Application is hereby made to San Joaquin CounDEPARTpq TT <br /> ty for a permit to constructand/or install the work described. This application is made mNcdmpliance with San <br /> I Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. I <br /> 1 L J+it ll�Nv �,,,11,�,,.^ ie Assessors <br /> WELL Location o Cross Street �v104a Y City „u'rf/(J Zip 1030 Parcel# <br /> PROPERTY 1�.`' II <br /> Owner i-t}v J) -6bo Address 3W 1� Olt .-&,s , city p zip ;Phone# X141-7ZLX) <br /> C-57 Contractor �CCrO�Q Address <br /> cityQonchzi 2 dJ7Y u-# i x747 Phone# %-A:513—l/0 <br /> Consultant/Sub Cntr .'I <br /> Sf=�� Address 3017 1 U.Lr City�i.�Lic# S-�fl9 Phone#, <br /> GIS Coordinates:X 'Y ,Township Range Section <br /> . WORK TO BE PERFORMED: <br /> I// <br /> NEW WELL/BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER') II DESTRUCTION (choose type below) <br /> # <br /> 0 SOIL BORING <br /> ELL# FK -t COVER-BORE. DIAMETER P <br /> o PRESSURE GROUT <br /> Q ther GROUT SPECIFICATIONS 1I <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 7 10LLOW STEM DIA.OF BOREHOLE <br /> Xa MULTIPLE CASINGS II MULTI-LEVEL WELL CASING DIA: 7- <br /> O EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS $Lf1 L10 TYPE OF CASING: O STEEL kVC OTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALEAL 3 TREMIE TYPE TO 8E USED: KAUGERS Q HOSE <br /> AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: [I Yes Quo (NOTE: MAXIMUM FREE-F,4LL DEPTH IS 30) <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS_ A&AL er- nn+ i' <br /> ()OTHER: D OTHER APPROX.BORING DEPTH Lh y IhBOLTED TRAFFIC BOX ori a STOVE PIPE <br /> 'I CONDUCTOR CASING PROPOSED NO O (if YES,list specifications in comment section) <br /> COMMENTS: 'I <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,and Regulations, and all applicable California State Laws. <br /> `' p <br /> Signed Title/Company� C'Li21� .S'f <br /> Print Name el l l lLshl Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 00 4-FaJ1 �a r� L0. W 0 <br /> WORK PLAN DATED: 1-5 'O <br /> ,I <br /> I (3 d ;1 <br /> Appli��c,,Itipn? q�,cepted By Date Issued <br /> S .Area <br /> Grouilnspeclion By - Da , 1) Final Inspection By Date <br /> Destruction Inspection By Date II <br /> COMMENTS/CONDITIONS: Vtrk4fj4-- !�. / •� <br /> ACCOUNTING ONLY: AID# FAC# ' <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# PERMIT/SERVICE REQUEST# INVOICE <br /> 4 ;ISO 1 91, $ 361 130t23 REC'D BY DATE sR# �l396 5 <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment clot_ <br /> i EHD 29-02-001 <br /> 6/22/04 <br /> I <br /> II r <br />