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FILE <br /> .n Joaquin Coun _ VEJ SITE COPY <br /> o > ��!( <br /> y Environmental Health De <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> • (209)468-3449 Fax: (209)468-3433 Web: w"UgopxegAw <br /> UNIT IV <br /> Well Permit ApplicatfWONRENT HEALTH <br /> �i PER�t17ss�vC�S � <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE <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. Z p?_o&'n­O <br /> -7 S n n b`'-, C T>_'� Assessors <br /> WELL Location ��y� ' Cross Street City [ Zip > arcel# <br /> PROPERTY nn�� (( � G <br /> Owners- +/ �l ah J Ik( llC'�ddress ?U'tgl6 S MA��rf��City ��,24'cfec�Zip g�7� Phon/e# 00 -7 �C' 33 <br /> C-57 Contractor C.'Z' Address 0 w 0�c" Ci t� t 7'0-' T'k-' <br /> E ty N� �'P'L'p Lic# Phone# <br /> Consultant/Sub Cntr Y�{�r-\ lr.�d.n `�Address � e/ City 2u5C��Lic# —� Phone# /�✓'/ t �v��� <br /> o' J( lcSection Coordinates:X'3 Y cS (o <br /> WORK TO BE PERFORMEDr <br /> 0 NEW WELL/BORING (CPT. -FnPRr)RE. HYDRO UNCH HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> ,',SOIL BORING# _ OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE Z 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYP/E OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL G> - TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE GUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> t(�9011­BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 61—_5 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED y (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 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 x --- Title/Company ��n e� L' �Si 1- <br /> Pri ame ef 1 i7@ %'�� Date .t /�ls C`7 `e / p� <br /> DEPARTMENT USE ONLY `7 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 1/ 7&uJCR — �� / Z <br /> WORK PLAN DATED: O <br /> Application Accepted By Date Issued f�'Z"10/ Area OW <br /> !1-S� }!^�A�! <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# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encprj�ment doge <br /> yl-� <br /> EHD 29-02-001 oz� <br /> 6/22/04 <br />