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oo San Joaquin County <br /> Q Environmental Health Department SITE <br /> W { 304 East Weber Avenue, 3rd Floor,Stockton, CA 95202 MITIGATION <br /> t' (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. <br /> (� �R R� Assessors <br /> WELL Location Nzc-,►�wAy �I� Cross Street City C-LEM k)TS Zip Parcel#_ aL:1- -0 S <br /> PROP' RTY �jj X sI� uP/11L/1 95��� <br /> Owner Nk1LE MPHR rEMS Address City ip hone# <br /> t �1 WEST <br /> C-57 Contractor�gO�R COAtt4L 4&V Address 391 I W&sT C'ApliTo At�ity Saca4►tswr�ip°156�1 Lic#'q4�hone I6 �3-J-(6 6 <br /> t W*A �i SGI'tTi d00 <br /> Consultant/Sub Cntr_(�ra c.. Address 10C)C} ��6AtaW44Y CityC7AKlAA/D Lic# Phone#(6/6 ab i:3-oy61 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ANEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) D DESTRUCTION (choose tvoe below) <br /> n SOIL BORING# J]OVER-BORE. DIAMETER <br /> I WELL# IEc�fJ1% Tt f� E .�) i'If:2ly)rTt}; ()PRESSURE GROUT <br /> 'Other GROUT SPECIFICATIONS <br /> COMMENTS: PIEc'Q/ IOC-k (,r-- b TO <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> !f <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 J PVC n OTHER: <br /> VAPOR *MUD ROTARY DEPTH OF GROUT SEAL oaf f TREMIE TYPE TO BE USED: n AUGERS I HOSE <br /> Q AIR SPARGE/OZONE n PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 1 Yes n No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> n SOIL BORING n HAND AUGER GROUT SPECIFICATIONS RRT44V7i OE/ dfl. I &'wl skg;, 43 <br /> OTHER:PIEZMETER n OTHER APPROX.BORING DEPTH Sl0 BOLTED TRAFFIC BOX or n STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: 8`rJ�j/G� l� ���,L�1� -�'y-To <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 R ulations, and all applicable California State Laws. <br /> Signed x Title/Company �gsOC.tCL44- �ULae <br /> Print Name t--e.Ay"'C j JCLYbSG�(!� Date - 1-U <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Eb rn U D <br /> WORK PLAN DATED: 7 Q . ^� Cc <br /> Application Accepted B' _ Date Issued //a�/bJ Area <br /> Grout Inspection By Dale I D L 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 /> ,10 a/0 /Y ? S R# 5 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EH D 29-02-001 <br /> 6/22/04 <br />