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San Joaquin County <br /> z 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 /> ` FORS` 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 Titl ,Chapter 9-11153 and the Standards of San Joaquin County Environmental Health Department. <br /> 1� I Rd.-city <br /> , Assessors <br /> WELL Location Dawn ""Am S Gih1 "Am e Cross Street Ccy-d /moi. City Zip Parcel# O23-210-p f <br /> PROPERTY ►eeSel-vo�r PWe 3 11 <br /> Owner r=:g M(/D Address .37,S- 67Z- ^City OAK/Ar>d Zip�ozPhone# <br /> C-57 Contractor /yic 7s/ Ik,4 IJSA Address ,389 3inCn/1.(A.'/-}v2 City oC K i Zip—Liic# Phone# <br /> ter. <br /> Consultant/Sub Cntr Address City Lic# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ,ANEW WELL/ BORING (CPT,GE,QPRPaE,HYDf�OPUNCH,HAND-AUGER OTHER*) p DESTRUCTION (choose type below) <br /> ;ff-SOIL BORING# 1 ` ►M�l CeLL 175'4) Q OVER-BORE. DIAMETER <br /> RWELL# 3 3 (Camp I�+�.1 p PRESSURE GROUT <br /> 0*Other l GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECT ICATIONS <br /> ii <br /> MONITORING gHOLLOW STEM DIA.OF BOREHOLE,5"'I MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL XPVC 0 OTHER: <br /> 0 VAPOR MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 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 /> 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 StateLaws. 7 <br /> Signed x� Title/Company 'E— Laws. <br /> DC SsOGi.C�P �;✓;/ ci,q r <br /> Print Name_ �pS�^ Qom, Date 12 7 <br /> DEPARTMENT USE ONLY C-5- <br /> SITE <br /> MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: IV <br /> Application Accepted Bj Date Issued / t'5 rU� Area <br /> Grout Inspection By 0 Date <br /> 12f,l CS Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: t r <br /> ACCOUNTING ONLY: AID# FAC# ' <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> g'q f ��saq �s SR# <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 />