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OPgU�:N,C in Joaquin Countk W� (�� ED FILE <br /> Environmental Health Department SITE <br /> Q <br /> < 304 East Weber Avenue, 3rd Floor, Stockton, CXR 62 4 2006MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www N%ik* HEALTH UNIT IV <br /> Well Permit Application PERMIT/SERVICES - ---- - - <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 /> ,� / Assessor <br /> WELL Location /V v// _—Cross Street I�' "r City �U .S ip�S��ib Parcel# —4 0-13 <br /> PROPERTY <br /> Owner Mac /t Ac Y�b� Address 1 d�i d( wt �>/A/l�7iil^(�ity. Zip Phone# �o <br /> C-57 Contractor Tv i+CA /M�PrtZc Dn 1I��VMddress �Iq 5 `'yyu(�Vly,0I/` City ` �,Z1ip�S�UZLic#� Phone# 11 6 6J(f b� <br /> Consultant/Sub Cntr SAI Address C� �Owk City OaIC�GeC�Lic# Phone# <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 4t-NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> ,11:�Other4A,,L /17 L-Inf ( /��� (� GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE 2" a MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS — TYPE OF CASING: p STEEL a PVC 0 OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL IC TREMIE TYPE TO BE USED: a AUGERS a HOSE <br /> a AIR SPARGE/OZONE.3a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ,SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER:_0 OTHER APPROX. BORING DEPTH Ire t BOLTED TRAFFIC BOX or a 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 h I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordin c RuI and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company S , AA C` — kAi, - l— <br /> Print Name PA It-kk& v Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: l'4�-� [� <br /> WORK PLAN DATED: l0 �4--Ok <br /> Application Accepted By Date Issued d Area <br /> dw <br /> Grout Inspection By Date Final Inspection B Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REV BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> p� 1A` S # <br /> C-57 V WC -WAIVER C-57 Letter of Authorization to sin ermit K Encro ment doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />