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urN San Joaquin County <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 /> �P <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. <br /> x:330 1 Assessors <br /> WELL Location C"QD RD, d�-rro�i tri Cross Street H W t( 1? City CLEMFu'rS Zip Parcel#0a?3-I`tb-")$ <br /> PROPERTY e y <br /> Owner fit_1>'U A ,r iZAce hrcj4naeAddress d &X 6A City Cte ey stip 7 5 Ph e# <br /> WEst <br /> C-57 ConVaclor Tgt=R %otusuLT�u rS Address 3911 Vxir G►os�u. Avg City5.4aAA4kP n Zip Lic#46ba�b Phone#(q16 34j-)6q0 <br /> Swire-105 <br /> - <br /> Consultant/Sub Cntr(�Le,- mow• Address )OX BWpv�y City O2Ak-L"V Lic# Phone# <br /> GIS Coordinates:X _'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ,NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) p DESTRUCTION (choose type below) <br /> a SOIL BORING# a OVER-BORE. DIAMETER <br /> - <br /> I WELL# U'CD9 1 f3-&Pii PICL!ri>F_i a PRESSURE GROUT <br /> a"Other GROUT SPECIFICATIONS <br /> COMMENTS: PiEZUr)FTE.(,E, OC—Eb-Zi REaAb C rJrJC t TFR �1F� J <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ' hAONITORING 0 HOLLOW STEM DIA.OF BOREHOLE (C a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL I PVC a OTHER: <br /> a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br /> a AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: I Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS FCKTL[�' J a�./V7., C4 (4)L11 57 � <br /> BOTHER: P1(Y4Y ITJ� U OTHER APPROX.BORING DEPTH BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: 8'6-ft 7-,'VQ'( � 54'-fIC,) -7b Zi(/,)'EQ-y_) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi nces, les a Regulations,and all applicable California State Laws. p' <br /> Signedx Title/Company ASSae'tea>� 6 CuG-ao WG�7� 1,IJ0 <br /> Print Name so,V% 0-y� Date 7- Z i-os- <br /> DEPARTMENT <br /> USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS' I�►'ll.( 0 <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued "7 /a f J -5 Area <br /> Grout Inspection By Date g 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 /> SR# Ll l7 <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 />