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COPY <br /> o0.At-qu l,N C U <br /> San Joaquin County 'T <br /> Environmental Health Department' � �l� SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 95�0,,3i� MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd� LQ)] UNIT IV <br /> "ylji Si= JI i. . <br /> Well Permit Application p�R"�iT�SEf NI EM <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 /> g7, �6 �J�( G ,- Assessors231I3I�Dj <br /> WELL Location�2�+�'f-LY��^,/ � Qp T�_'�']'�1[f Cpro�s�s Street /�' City ONT q Zip qr Parcel# l <br /> PROPF-IM6/+ A/ JrOH-f��Avdress --JIp3$ q 16GI 1 333fl <br /> Owner__ lV[i�+JJ/'<� $•�-L p2/� [yCfty esty;llG Zip p� phone \ qq <br /> C-57 ContractorWDL ex'PI#fllp'f W4A(tlress958�7Cov / /3(�C�ity7��1fN10`f,Q LZ,ip I Lic4SY,126 Phone# 530/ <br /> Consultant/Sub C//nttr�r E(0�i 0611 rcy19•—Address T u-►� y /f! '"CTty i'# Phone# D?-Zy Z'OZ9Z <br /> GIS Coordinates:X�r1 �5�6 "ITa•)Z�9 Loi Range Section <br /> WORK TO BE PERFORMED: <br /> "-'NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# /���// ` D 0OVER-BORE. DIAMETER <br /> %WELL# INC O /I'(,{[(/ �J A ��06 0 PRESSURE GROUT <br /> Q'Otherrr GROUT SPECIFICATIONS <br /> COMMENTS: 0�7: I W?1 Gulf? LlO.Cl�+�" e ;22/ /W- VA..7?- QG(�ra.o <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING )-IOLLOW STEM DIA.OF BOREHOLE tr Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION O AIR HAMMER/DRIVEN CASING THICKNESSy_TYPE OF CASING: Q STEEL PVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL + 1c' TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> Q AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes a No (NOTE: MAXIMUM FItE�LL DEPTH IS 30') <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS N�ii' E+VT Z5 // <br /> Q OTHER:_0 OTHER APPROX.BORING DEPTH Lfl-zS•F& Q BOLTED TRAFFIC BOX or/KSTOVE PIPE <br /> .,[CONDUCC,JOR. CASING/_PROPOS D (if.YES,llist specifications in comment section) <br /> \ <br /> COMMENTS:�K/J's ✓f r:// / '�r <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certi that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Or ' ces, Rules d Regulations,and all applicable California State Laws. <br /> Signed x ) - / Title/Company at toe QP r <br /> �ll <br /> Print Name ! /7Qr*�j �[1'TLF�C Date 2 I 6 <br /> DEPARTMENT USE ONLY o� zp�r <br /> SITE MAP IN UNIT IV FILE, ADDRESS: /Zzt <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued ��l T Area W <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 /> �O 7t l P7 1 (1777,(? j' I SR# <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 />