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San Joaquin County <br /> . 0 <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> l (209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br /> UNIT IV <br /> I�0R 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. <br /> r7 1 � 7 � , 1 1 _ 61., 1� Assessors <br /> WELL Location /01) Q10 V N, 17 nk yr Sf Cross Street nt✓k S . City Nuri ip99202, Parcel# 14 & <br /> PROP TY <br /> Owner��.tai'S/ Fa^ lckIII TNQ I�oddress34SN �ldovcrl� SF, ciry S4-or��-on rpp D2 Phone# 2U 937— F�349 <br /> C-57 Conlractor(TYi?Q�iT 1�,,'VACr AddressG50 14/v'Je IQta A ✓1 � .tcityMOr LInz Zip ? 5 !Jd4 -jQPhone "2 "`313 '5 CO <br /> Consultant / Sub Cmr ri zed(� � Address M77 aWKPIrd City.5�rkAd7 Uc# Bf7.22 Phone#(aC7q)q­67 ^/bio <br /> GIS Coordinates: X , Y , Township Range Section <br /> WORK TO BE PERFORMED: <br /> PEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) U DESTRUCTION (choose type below) <br /> $SOIL BORING # 0 OVER-BORE. DIAMETER <br /> n WELL # 0 PRESSURE GROUT <br /> U *Other GROUT SPECIFICATIONS <br /> COMMENTS: TWD 00r1 !2$ 4 Ca e ( Pr I OCrnl-l ' t> 0 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ,II <br /> 0 MONITORING a HOLLOW STEM DIA. OF BOREHOLE a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: �N <br /> g EXTRACTION U AIR HAMMER/DRIVEN CASING THICKNESS N A- TYPE OF CASING: U STEEL a PVC 0 OTHER: <br /> 0 VAPOR u MUD ROTARY DEPTH OF GROUT SEAL Gh I-1 rt TREMIE TYPE TO BE USED: gAUGERS a HOSE <br /> u AIR SPARGE/ OZONE XPUSH POINT (GP or CPT) GROUT SEAL PUMPED: Ayes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ")SOIL BORING aHAND AUGER GROUT SPECIFICATIONS OOrN.r nr) LX uGowrl2 (PN 4At SC ry <br /> a OTHER: n OTHER APPROX. BORING DEPTH /� S / BOLTED RAFFIC BOX or a 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 prepared this application and that the work will be done in accordance with San Joaquin <br /> Countyorcrinances, Rules and Regulations, and all applicable California State Laws. / <br /> Signed : 1 / Title/Company Y�10) C,[..i—�-CA9�} S q� ' Ftf,VyeutAt_e� �CRJLtIU <br /> Print Na I � Y, IeI VC041M � CDate � C� � I � IZbC7S <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : <br /> WORK PLAN DATED : I <br /> _ <br /> 1 � <br /> Application Accepted By "L G/(/ 4 : Date Issued DC-1 7 U i ?O&f Area <br /> Grout Inspection By ✓ Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: t 'f 41�1 'Vile <br /> ACCOUNTING ONLY: AID# FAC# <br /> ii <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> 10 ZJ SR# S � 3 <br /> C-57_ WC=WAIVER_ C-57 Letter of Autho izati n o sign permit_ Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />