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S'an Joaquin County <br /> Environmental Health Department ^ `'J SITE <br /> 304 East Weber Avenue 3rd Floor Stockton CA•95202 MI IGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: <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 Sa Joaquin County Environmental Health Department. <br /> WELL Location 151 5,tmoo R5t �tAu/ S l-. y / Assessors// <br /> Cross Street City /�' Zip I52D l Parcel# 95 b3D_ / <br /> PROPERTY d '` r r / <br /> 0111-1 IM-1 1/0(566 (�`11-iUatfq Addres. 3� W, 50.44 �4f, City -5U Zip g52Z3 Phone#;OY-qGV-8 03 <br /> C-57 Contractorlw� "Ifa( $JJ4 Rp;� � <br /> CCll ''"� Address r!, city Yvb, C � Z;pq 99 L;C# $(� phone#t{80-2Z(o-.S'�B..S <br /> Consultant/Sub Cnt&—A- CAVI/bn 11 +j�� Address � "�&✓t R4( 0/,# C �/+�'at f Lic# 45�g Z Phone# 5.�0 G76 TO(o Z <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) p DESTRUCTION (choose type below) <br /> D SOIL BORING# a OVER-BORE. DIAMETER <br /> '50ELL# 0 PRESSURE GROUT <br /> Q*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 5e{' aRo d 2061 (.t i a f/uj4tS <br /> MONITORING a HOLLOW STEM DIA.OF BOREHOLE t@ a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _ <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL. PVC u OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS a HOSE <br /> 0 AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING a HAND AUGER GROUT SPECIFICATIONS -� i ex---t_t.i�'�/I <br /> 6 OTHER: `aOTHER 50n.C- APPROX.BORING DEPTH Q BOLTED TRAFFIC BOX or a STOVE PIPE <br /> cc;, // COND/�CTUR CArSIN�('PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: 5 -e K � I�'t /`r�5 iz"1 VuW 54 -T`Ck t�CM 5 ??IfiJ/!) �'� tkZm S����v 5— 1-'-, <br /> v <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 Ordinan. es, Rules and Regulations,and all applicable California <br /> f State Laws. l <br /> Signed G> I�I / Title/Company CIeO� i5rl ` IS41r4 �F/it':41 1, , ��/ <br /> Print Name 5ca,+ gj,4.,,,rff Date <br /> —V DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 1 q.z R L��2 ( �'� S G7 <br /> WORK PLAN DATED:_ / <br /> Application Accepted By >! t Date Issued l/a/�'�/ !� Area �L Z <br /> Grout Inspection By Date ttco Final Inspection By ! LLt?5;i), r/U 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 /> C-57_ WC_-WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />