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. San Joaquin Colunty` <br /> " Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> UNIT IV. <br /> Well Permit Applications <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - <br /> Jul �.�slr� co�lN�''� <br /> Application is hereby made to San Joaquin County for a permit to construct andtor.install the work described. This appli 0i8��vlijrAELwith San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health e� D EPARTHT <br /> 1� ssessors <br /> r' <br /> WELL LocationJ31�,1.-1 I E. ailLt Kt _Cross Street W�� City Zip Parcec I# ���J" �"D <br /> PROP <br /> OwnnerER ��1LS Address �rJ j1 Al?, City_ _Zip Phone# -I 3 h-il�D p �f <br /> C-57 Contractor Q� t �IMAddress 1�6D ��q C 4Alp t City 6? Zip �03 Lic# 67,0[l Phone# 1 e f '�l0TD <br /> r <br /> Consultant I Sub Cntr' Address A _7 S�yjU _._City�_Lic# Q Z Phone# t,`2.o1�K_7-06C <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') D DESTRUCTION (choose type below) <br /> D SOIL BORING# D OVER-BORE. DIAMETER <br /> WELL# I D PRESSURE GROUT <br /> []"Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS h <br /> XMONITORING ,HOLLOW STEM DIA:OF BOREHOLE D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: _ <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THiCKNESM.1Q_ TYPE OF CASING: a STEEL XVC 0 OTHER: <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEA1-70 TREMIE TYPE TO BE USED: D AUGERS HOSE <br /> p AIR SPARGE]OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED: D Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> D SOIL BORING D HAND AUGER GROUT SPECIFICATIONS 1'ofI � <br /> OTHER: a OTHER APPROX.BORING DEPTH OLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED t VO (if YES,list specifications in comment section) <br /> I� <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 t i Vt <br /> Print Name ttlrgyV1e_ L. eg�Aoc _ _ __Date 5 ToD5 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED' If <br /> Application Accepted By Date issued Area <br /> Grout Inspection By Date inal Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> I ACCOUNTING ONLY: AID# FAC# <br /> I PE CODES FEE INFO AMOUNT REMITTED- CHECK# REC'D B DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 350 ti B ' s coo 2Z22- SR# ZtL-3`t <br /> C-57_ WC -WATVERT C-57 Letter of Autho !za o sign.permit_Encroachment doc� <br /> EHD 29-02-001 <br /> 6/22104 <br />