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oeviM II' • San Joaquin County • <br /> ° Environmental Health Department 2 SITE <br /> 600 E.Main Street, Stockton, CA 95202-3029;., `, MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> i <br /> !Pi}R 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 applicationis 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 /> SS CC A v A r��1�1 Assessors rr �1 <br /> WELL Location 1gD(� h• 1 ISC_ &e- Cross Street iJi "City CC Zip _7JJC Parcel#�qz�'I"!�'-'1 <br /> C-�rri <br /> PROPERTY ei S <br /> OwnerCoMjj1 .PMSIRy!t4rP Address P.6 &'k IC's Cit/y <br /> /f ^ Zipq73yhoneq�r "� <br /> lG <br /> C-57Contractor ] ` 1 AddressC/i1Q LgCitynt 9 <br /> ip!J �� Li X33 hone#�730i--2 iJ <br /> Consultant/Sub Cntr�A Irl Iil-l�'1. L� ,C. Address r 1�'Ci � F Uc# Phone "..,SJ <br /> c�, p% . ,1 )"' is . <br /> GIS Coordinates:X} �ft�� �7M-,YIZI I �:- ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> I NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION (choose type below) <br /> I SOIL BORING#�d OVER-BORE. DIAMETER <br /> 0 WELL# PRESSURE GROUT <br /> 0`Other GROUT SPECIFICATIONS <br /> COMMENTS: - <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING a HOLLOW STEM DIA.OF BOREHOLE_ a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE (PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ®SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_G OTHER APPROX.BORING DEPTH 9b d-ft D BOLTED 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 certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. s <br /> Signed z J 4L(.r?L 'yy/��' G7t'a rL Title/Company `4" ` .� 6 .r+�el{1 7— ed �e-- <br /> Print Name ^�Q-4rI.e.L 'k !.�1L]lLG r7 Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 11 L s) r--I < ` ,iS 2 A"-!' � K1 iT r <br /> WORK PLAN DATED: 0'%(�� 1 I 2,00-7 <br /> Application Accepted By (/7� -�\ Date Issued i �/J Area i % <br /> � —fes' <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 C,KEC-# RECD BY DATE 0 PERMIT/SERVICE REQUEST# INVOICE <br /> L t 15 7 lel r?[ SR#0 �r ..i i <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 web <br /> 6/22/04 <br />