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N./ <br /> San Joaquin County - __- <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 /> 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 <br /> CDepartment. <br /> WELL Locatlon- � ��a� 5'Llvl;�C oss�Street�city ( Zip (Jo20`p Pastel#rs [q <br /> PROPERTY_ / C(-Gk� Address 5 ry 51 DD^14 L o <br /> Owner � Ut" J ty � � City_{ �� Zip �jJ`ad� Phone#�by-/,3�-8.39 <br /> lI 3(030, (�me( (4 rti° city_ Cc'r LVA zip �1f2Lic#7115/0 Phone#V 6A//Gy <br /> C-57 Contractor S �, i Address �y- �' <br /> Consultant/Sub Cntr r411�J Fyl✓Ilor{�YtA-t {��Address 4W1Q/bi1 Pu �/., CityJ ��+I�n)°Lid��542 Phone# 530'.O�(l'—Z�Z <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> "EW WELL/BORING/ (CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> a SOIL BORING# a OVER-BORE. DIAMETER <br /> a WELL# a PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING iOLLOW STEM DIA.OF BOREHOLE_I a MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL a PVC a OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: n AUGERS a HOSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes ro- (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> U SOIL BORING �1AND AUGER GROUT SPECIFICATIONS n f.GwtRj <br /> a OTHER: 0 OTHER APPROX.BORING DEPTH o BOLTED TRAFFIC BOX or a STOVE PIPE <br /> O L J/ CONDUCTOR CASING ROP SED (if YES,list specifications In comment section) <br /> COMMENTS: See QT Ot( J5/riMS ukfll �Ci iL 14 <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 <br /> �(Rules and Regulations,and all applicable California State Laws. <br /> Signed x - J 4#_ I I��lijD°I '� Title/Company (�1 k i5 �zal�s S? Ui(Ortyrte�cf+r�� r <br /> Print Name Scb-4 b.74+ jPf Date <br /> u DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: / 4 a'6, S • / !/- - A'-, <br /> WORK PLAN DATED: MY d 7 <br /> Application Accepted By ✓m Date Issued `� d Area y <br /> Date Final Inspection By to 3 <br /> Grout Inspection By o n <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C� 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 />