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FILE COPY <br /> UV�pP,ayN.,}co fan Joaquin County <br /> z i Environmental Health Department SITE <br /> GP <br /> X MITIGATION <br /> rO <br /> 600 E. Main Street, Stockton, CA 95202-3029' )468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehdL UNIT IV <br /> Well Permit Application <br /> 6, ca s <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby"mado to i$an.J08quin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Develnnr --1,T,«_ __.__ 3 and the Standards of Sa Joaquin County Environmental Health Department. <br /> ,{� j,�J Assessors /'I <br /> WELL Locatio,. N. Cross Street City g`` Zip Parcel# <br /> PROPERTYC, L / �// Af �� -/ y � p �! /� <br /> Owner r B 5�.K 17� Address n��V• �i711�C_I Cit Zi Phone# T•- <br /> vsd7 <br /> C-57 Contractor Pre w- Address 10 t c� A-e City tYl�ovv�Zip %N80/ Lic# Phone# JO-z37- 1575 <br /> Consultant/Sub Cntr Geo Address 128 Ci. ity *%WJ Lic# Phone#�O-26V' 2,53 S <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> , NEW WELL/ BORING (CPT GEOPROBE HYDROPUNCH,HAND-AU HER*) Q DESTRUCTION (choose type below) <br /> SOIL BORING# Q x/O44; Q OVER-BORE. DIAMETER <br /> Q WELL# /V Q PRESSURE GROUT <br /> Q*Other /[ GROUT SPECIFICATIONS_ <br /> COMMENTS: Cln�✓drCril1 w.cw� /%�'/1,Zi� 7/ 7� a <br /> • v <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 'MONITORING Q HOLLOW STEM DIA.OF BOREHOLE_J�Z Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA:Z­ <br /> 0 <br /> Z _Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL PVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> Q AIR SPARGE/OZONE)USH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes Q No <br /> (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS /Y4t� CEr+,�C�7— <br /> a <br /> Q OTHER: Q OTHER APPROX.BORING DEPTH j D OLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED \ (if YES,list specifications in comment section) <br /> COMMENT-_ I� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rule§j and Regulations, and all applicable California State Laws. 1 `/ <br /> Signed xJ Ale <br /> f J Title/Company GeoWITio-k �✓iS��7T�lvL7� <br /> Print Name AleX �qY/� Date � ��- U / <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <-� x)• <br /> WORK PLAN DATED: ZOOS <br /> Application Accepted By Date Issued ' "0 7 —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 I SERVICE REQUEST# INVOICE <br /> ZQo SB OCY /2 3 qog- C0t- 7-13 SR# p© :�5-1 3 6 <br /> C-57-j" WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001web 7i O <br /> 6/22/04 ` <br />