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Nov 29 05 12:47p Peter Weiler (9938-1610 p.2 <br /> San Joaquin County <br /> r' 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.org/ehd UNIT IV <br /> ql%Fo ��a 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 andlor install the work described. This application Is made in compliance with San <br /> Joaquin County Dlopmeri TitIr apter 11 a e ardards of San Joaquin County Environmental Health Department. <br /> K K-e J--�� 1 s f Assessors <br /> WELL Location �� ��I C e S Cross Street��c_ ��� SC�City S ^ Zip�l Zp}Parcel#, ^(2,7—©0 <br /> Z. <br /> PROPERTY • e <br /> ` City Zl7 <br /> a <br /> Owner Ciip ZSlt Phone# a I�t y 1>`E1 L- <br /> ty. Zi°l`fS1l ;- <br /> 1y.4t1e-6 <br /> C-57 Contractor S o <br /> Consultant iSubCntr 5 Address 12 ►1, �o "`r+ City Li,c~�'�� Lic# ZClStb57 Phone# <br /> GIS Coordinates:X->I 1S> -1, -fill,5'j,Y 1 i 1, 22�t 7.51 <br /> �ylfownship Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> ',SOIL BORING#. I O Q OVER-BORE. DIAMETER <br /> WELL# l ( q•A� Q PRESSURE GROUT <br /> Q'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS/111 <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE 4i Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA:Z _ <br /> p EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS C `}-Q TYPE OF CASING: 0 STEEL PVC Q OTHER: <br /> p VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL �?,o TREMIE TYPE TO BE USED:X <br /> AUGERS Q HOSE <br /> p AIR SPARGE/OZONE Q PUSH POINT(GP orCPT)GROUT SEAL PUMPED: Q Yes p No (NOTE: MAXI UM FFf E-FALL DEPTH IS 30') <br /> U SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS '•� L � '� "`� "� '^' '� <br /> 1]OTHER: p OTHER APPRDX,BORING DEPTH .+ d _Q BOLTED TRAFFIC BOX or p STOVE PIPE <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 /> I hereby certify that I have prepare is application and that the work will be done in accordance with San Joaquin -- <br /> County In es, Rules an egu tions, and all applicable California State Laws. <br /> Signed x TitI&Company <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP 1N UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: / J <br /> Application Accepted ByDate Issued �( � Area ?917 <br /> Grout InspectionSy Date nk' Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 01 SR#0o S O$ <br /> C-57_, WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment dac_ <br /> END 29-02-001 <br /> 6/22104 <br />