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San Joaquin County RE HIEN' <br /> Environmental Health Department EIVED SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 9520 2 8 2005 MITIGATION <br /> (209)468-3449 Fax:(209)468-3433 Web:www.sjgov.or e <br /> DUINI <br /> Well Permit Application S�NVIRONMENTAL COUNTY UNIT IV <br /> uF�TH DEPARTME 10 <br /> NON-REFUNDABLE PERMIT EXPIRES 7 YEAR FROM GATE ISSOED W JJ <br /> Application is hereby made to San Joaquin County for a pennh to construct and/or Install the work described. This application is made In compliance w <br /> Joaquin County Development Tide,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location ~ dv015l� of ZrV�au�,( Cross Street EAr TNIDD/' •- Assessors 2 _ <br /> ') <br /> G/b5� City ,LZip $31D ParceHl ddD' 57 <br /> PROPERTY rrJJ //'� �_ 'P <br /> Owner /,fkgf[Ixi&(Ft I ily� Address /P/v CCxll/'A CityA�/014a'0d°'Zip nY Phone# <br /> C-67 Contractor f Address a' 3 r,5 GJ,� „��Lwr Ciiry S- N ZIp Lilt S/� Phone#p�`��s-S'�/';2- <br /> Consultant l Sub Cntr /1 /�/"V Cl�'�� Address ��.���/ 'Y�L Cay Lid# s/OAS Phone# <br /> GIS Coordinates:X ,Y Township Range Section <br /> 1 WORK TO BE PERFORMED: `/ <br /> n NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type low) <br /> O SOIL BORING#y}--�� / "OVER-BORE. DIAMETER S" /F�r551X7 <br /> ''�WWEELL# I�r r/O n PRESSURE GROUT <br /> do*Otl],er _ GROUT SPECIFICATIONSNeat <br /> /Iest+-� <br /> COMMENTS: f5f �� �D pdirt(rOOrbp,✓6& WA /'act', �&41114$/✓j'tI USG �$% ks '77Cv�rrl tC � G/655 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 'MONITORING n HOLLOW STEM DIA.OF BOREHOLE_ n MULTIPLE CASINGS n MULTI-LEVEL WELL CASING DIA:_ <br /> n EXTRACTION n AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: n STEEL n PVC n OTHER: <br /> n VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: n AUGERS n HOSE <br /> n AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: D Yes O No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> 1]SOIL BORING IIHANDAUGER GROUT SPECIFICATIONS <br /> n OTHER: 0 OTHER APPROX.BORING DEPTH n BOLTED TRAFFIC BOX or n STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (f 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 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 /> v / / <br /> Signed x % 164Ae'6i 4 Tale/Company <br /> r�NLs/a�lod7�0 /5� /c/P/r✓�2'�GtJ <br /> Print Name [5 Ir�/1(./�L` A, Date X15 Quo <br /> DEPARTMENT USE ONLY / �p <br /> SITE MAP IN UNIT IV FILE,ADDRESS: /NG�/D A35A0E 1;2-1— eF"4 /Zbt4�l��lcede `/ <br /> WORK PLAN DATED: ' <br /> Application Accepted By Date Issued 7S�j <br /> I (0 Area D <br /> Grout Inspection By ie Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUE T# INVOICE <br /> 29py ra60.DIO I2d 7194(q, SR# 3 <br /> C-57_ WC=WAIVER N C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 622/04 <br />