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a4�!1cSan Joaquin County <br /> �••..rF� o <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 <br /> c•.. _:; ,-. P 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 /> ^� <br /> S2 Q C+ L� S t}>° _Cross Street 6r N' City tt10 V- <br /> WELL Location Zip AssessorsC15 yj� Parcel# 209 -(45-0-o-L <br /> �1 <br /> PROPERTY. �" <br /> Owner t1UL.,�-j(O�(6 cSrAddress 25810 uLC%. >-14-e cityL- Vej1"(n6,r--e Zipg455-1 Phone#g2s'2-q51-30q(P <br /> p ( 10) <br /> C-57 Contractor?YZUSICA-SOAP( Address 1031 LSSe-X ]f(P. Ceitly 1 vt ip94&)1 Lie# 3M, hone# 2337-45 �S <br /> Consultant/Sub Cntr 4e. Y-L1.S2t�' k 16(. Address 2-51 �XOS,�1✓eCity Ijyy `�(Lic# Phone#C1L5� <br /> GIS Coordinates:X 'y Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,6iEiHYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> SOIL BORING# 2.14 a OVER-BORE. DIAMETER <br /> []WELL# []PRESSURE GROUT <br /> Il*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS []MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC 0 OTHER: <br /> []VAPOR Il MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: []AUGERS a HOSE <br /> a AIR SPARGE/OZONEPUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING /a HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER:_0 OTHER APPROX.BORING DEPTH a BOLTED TRAFFIC BOX or p 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 /> County Ordin c s RuNs and Regulations,and all applicable California State Laws. <br /> Signed � Title/Company 5AaR Geo ` � e r search 1 C, <br /> Print Name Kk' Aif�[C G:VCkA S Date 27 �00 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By. Date Issued Area <br /> Grout Inspection By Date 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 /> S R# <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 />