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..'an Joaquin County <br /> Envircnental Health Department SITE <br /> .: <br /> `�. 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 /> Well Permit Application <br /> C 0 P VON-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, <br /> r � �Lz <br /> Chapter 9-/11,15.3 and the Standards of San Joaquin County Environmental Health Department, <br /> sesso <br /> WELL Location G`�` Vat ;- 7 Cross Street T ij;e Leiswjty �' "�'L Zip `l Parcel# rs/4!3 3 1 00( <br /> PROPERTY• _ C� <br /> Owner__("!-�j^'f Address_ D ! L���! 7 Ciityv5/ e_� (�i ��7hone#f7 j gyp" � <br /> C-57 Contractor 1� ` ��Q— Address bt'O K� '`b i 'r` ty YR 7 EQklZip9 �Lic# �1J714'Itone# 7/7�� 6' <br /> onsultant Sub Cntr Ab Address ?.SftAA 0 12 City *Z ic#10Z) �phone# ,v-) <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> U NEW WELL 1 BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER*) DESTRUCTION (choose type below) <br /> 0 SOIL BORING# . VER-BORE. DIAMETER <br /> Q WELL# PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> )e <br /> MONITORING OLLOVV STEM DIA. OF BOREHOLE MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 11 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS L, TYPE OF CASING: 0 STEEL 10VC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 111 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING jl HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_0 OTHER APPROX. BORING DEPTH BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br /> COMMENTS: t S <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. <br /> Signed `^J_ "1� / Title/Compa'j <br /> Print Name fes/1 ?� 'rn C if Date Aq <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 2- 1 q lr' <br /> WORK PLAN DATED: 'I 1 13j. 2-006 <br /> Application Accepted By L Date Issued 6121rilZ601, Area /4%5:9 <br /> Grout inspection By Date '94- 17-0 G Final Inspection By ate_-_ <br /> Destruction Inspection By 17 Date <br /> COMMENTS 1 CONDITIONS: r h - --4 - - <br /> ACCOUNTING ONLY: AID# F <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 35o Z i #60 <br /> 35o 3 .21g 3.3�' 00 SR# Q� 5 <br /> C-57^ WC�-WAIVER C-57 letter of Authorization to sign permit Encroachment. doc <br /> EHD 29-02-001 <br /> 6/2VO4 <br />