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FILE COPY <br /> San Joaquin County <br /> Environmental Health Department SITE <br /> y' { 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/ehd UNIT IV <br /> ��_FORa 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 Department. <br /> _teAssessors �J <br /> WELL Location �Z06 f��ST /�'/l fz-y A", Cross Street 14651" 14� City /G>, T"�� Zip ���/G Parcel# OV <br /> PROPER �VI �vi sr�j`'544. P�� is D/�A �� /p!c <br /> Owner V --'r----C ddres dCit V ip a Phonee7ne�# ;W' <br /> l <br /> G <br /> C-57 Contractor s��C ,GrG *� Address 3,6. 2 D.ysG CYILyy City La test/ Zip�7 Lic 6G7G <br /> Consultant/Sub Cntr s6��� Address 3Q/7 �iGyv c� 12--oCity lid Lic# Phone# <br /> 5.r-/CV <br /> GIS Coordinates:X Y_ Township Range Section <br /> WORK TO BE PERFORMED: <br /> XNEW WELL/BORING (CPT,J�EOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) Q DESTRUCTION (choose type below) <br /> rSOIL BORING# h Q OVER-BORE. DIAMETER <br /> Q WELL# Q PRESSURE GROUT <br /> Q*OtherXr ''11 / G�UT SPECIFICATIONS <br /> N07- V0 <br /> COMMENTS: U��w �� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING HOLLOW STEM DIA.OF BOREHOLE- 8'/, <br /> / Q MULTIPLE CASINGS []MULTI-LEVEL WELL CASING DIA:______ <br /> []EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL Q PVC Q OTHER: <br /> Q VAPOR (]MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> []AIR SPARGE/OZONE []PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes Q N""o/�(NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING []HAND AUGER GROUT SPECIFICATIONS <br /> []OTHER: []OTHER APPROX.BORING DEPTH Sd Q BOLTED TRAFFIC BOX or Q 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 h ve prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinanc 7, les nd Regulations, and all applicable California State La�ws../��y/ <br /> Signed ,� Title/Company___ <br /> Print Name <br /> C /� Date / �l,5-- <br /> DEPARTMENT USE ONLY / <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 12-0 c' 1�• <br /> WORK PLAN DATED: .25.os <br /> Application Accepted By ��� Date Issued U J Area <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 /> �Plo /•?�" sR# -b 1) <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment docA <br /> 6/22/04-02- 0II'/,6` ��� <br />