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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> r <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone: (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 /> -701 W ltio b� ja�. Assessor's <br /> �, �►_ _ ',f y k+vr Zip 95203 Parcel#_(z7-26o-16-i6 <br /> Well Location fr� Cross Street�tf1�3�"��,,fWt��e.r v� Cit �8c <br /> OwnProer � J �T �JE-ta� l�s�n Address "i 2, NV G—1 �oFAJ City G� Zip16?4 2-'Phone# <br /> C-57 Contractor V�VJ l3ri It j" , 3;X• Address �.O• Dox 170 City I ndl; Lic# TlOgOl Phone <br /> Consultant/Sub CntrUJ.11, ,- k/,i(y hic. Address 35 1 Be-a-,-a, t IvE[ City W& A Lic# Phone MI C0 37 Z-6y 3Y <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> l NEW,WEL L!BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') f56 DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# D P-i OVER-BORE DIAMETER <br /> ❑WELL# PRESSURE GROUT 1Je,+ <br /> ❑*OTHER GROUT SPECIFICATIONS <br /> t`2t <br /> p rr F t ba�kil P� I0 >b oy� 1 !�a (SRao55q�2) <br /> COMMENTS: ,c ou.5Vl ��T} a,troa srk :e. 0. an lc <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> v <br /> ❑ MONITORING ❑ HOLLOW STEM DIA.OF BOREHOLE [--] MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY <br /> /� DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED[IAUGERS❑HOSE <br /> ElAIR SPARGE/OZONE ( PUSH POINT OR CPT) GROUT SEAL PUMPED:❑Yes ❑No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> I SOIL BORING ❑HAND AUGERGROUT SPECIFICATIONS C�i✓�2/1^J� <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 2� T3' ❑BOLTED TRAFFIC BOX OR []STOVEPIPE <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 I accordance with San Joaquin County Ordinances,Rules and <br /> Regulation all aplIplicabl a'forni Laws. 2� <br /> Signed � l Title/Company 5C S} ,4 ��i,�R(I�P-GC,.1�( ssec <br /> Print Name /vic_{Ic Ke.,r —6-s k6s Date 73 4/04 <br /> —t DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: p� ! I Uj <br /> WORK PLAN DATED: 3)14 I 1() I <br /> APPLICATION ACCEPTED BYN BY DATE I UED 3 i ;13 <br /> AREA <br /> I f q <br /> GROUT INSPECTION BY FINAL INSPECTIODATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> SR#5;?33 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> Cull 70 f,A AA/G l��/I,lIG 01 Wrl I OFRI,AIT GPD <br />