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aqu►N kn Joaquin County <br /> o ••c <br /> 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 /> 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. Zja_o I <br /> WELL Location} o ASS- t F,o �a L-o.c Ts Cross Street IJ ?� a� Cit S E oo Assessors t- Z <br /> � 1 � y �-l-o� Zip r'1 S Z�� Parcel# <br /> PROPERTY I 220 t �. �usI, -,L3V - / <br /> Owner{hoc?- Address City SA G�41-^ Zip v3 Phone# <br /> C-57 Contractor -Address�>-bSS' C'. ��".Haft, Q,p City..T,�-LZip` S-76s Lic# Phone# <br /> Consultant/Sub CntrS Coc Address 21 2( K3.Cal'•tc-­•.VI- Cit <br /> yC cr k Lic# ,G�Sl6 Phone#�� <br /> S t-c. `0.'L-- <br /> GIS Coordinates:X217`( o'- o4 ,Y C2,p23IS-(Q1Sa ,Township Range Section <br /> WORK TO BE PERFORMED: aye <br /> 0 NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING#_ _ OVER-BORE. DIAMETER <br /> vVELL# PRESSURE GROUT <br /> 0*Other + f GROUT SPECIFICATIONS <br /> COMMENTS: z . Ie "i z�� S�cc'_ � 9 f �dc:{�•, <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 2i TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS XHOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 4Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> �� �-2 <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 6�eH • 5 c, � ((...11, �e ) •- <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH (Z--z S ' BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> /- CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) 7� <br /> COMMENTS: (-UP-c✓ C CCK lSLer Sr-'^ <br /> ID <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, R and Regulations, and all applicable California State Laws. F <br /> Signed x Title/Company__ ?.S LoS� <br /> Print Name T -el Date <br /> DEPARTMENT USE ONLY <br /> i <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued �� �� ) Area -• <br /> Grout Inspection By Date V 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 /> R# 7 80 <br /> C-57_ WC--WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />