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ECUIV FILE COPY <br /> Pay L San Joaquin County <br /> 9, A 2Ef3vironmental Health Department SITE <br /> 4 ast.Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> ONk- <br /> #-#9 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> ERN <br /> Well Permit Application <br /> REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby ade 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 TiI}le,Chapter -1115.3 and the Standards of San Joaquin County Environmental Health Department. / <br /> �t F f"yO w1 w11 ter . (� y l �/L_ g Assessors <br /> rs <br /> WELL Location Tt=� Cross Street O�-`Jfi Cit 'T���u%7 Zip � Parcel# <br /> PROPERC(,, j j (�1 phone# �1 Vi7C)—t/ <br /> Owner ✓1 Cr'p. 51Q�'., SIG" v City C DA-1 Zip q�� (G <br /> C-57 Contractor y f1 I t'V Address- f.JV Dtt6( L� �Ci�tty ,.ri1 ip NWJLic# Phonedftpbs <br /> Consultant/SubCntr ^ Address�I�;,t1Y►�I�r ��ityJ«1 _.C# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORA11,G# 0 OVER-BORE. DIAMETER <br /> /YELL# ( ILt)— � 0 PRESSURE GROUT <br /> /0' they v GROUT SPECIFICATIONS <br /> COMMENTS: -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �J <br /> 1n; NITORING HOLLOW STEM DIA.OF BOREHOLE �� Q MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _ <br /> ,0,TRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS U TYPE OF CASING: 0 STEEL VC OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 3�Jt , TREMIE TYPE TO BE USED: 0 AUGERS HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: )Yes 0 No (NOTE: MAXIMUM FREE-F LL DEPT IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: []OTHER APPROX.BORING DEPTH "'.. OLTED 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 /> I hereby certif that I ave r pared this application and that the work will be done in accordance with San Joaquin <br /> County Ord' nce , RuI d Regulations, and all applicable Californi State Laws. <br /> �- n <br /> Signed x Title/Company lU� , 1 ✓` 17 <br /> Print Name ��� r. ) Date <br /> DEPARTMENT USJE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 00 C N` <br /> WORK PLAN DATED: 0 <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection By e <br /> v <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FIE�E�INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <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 />