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I <br /> San Joaquin County V <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.sigov.org/ehd <br /> UNIT IV <br /> Well Permit Application 205 MAY 20 pts l.: 26 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> SAN 3DA0UlN COUNTY <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install.the work described. This application is me �I0� H fah L <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Departmenf� L DEPARTMENT <br /> Assessors <br /> WELL Location 6 -2�s N.qq��I- D Cross Street 1 City Zip�ScL(/ Parcel# <br /> PROPER <br /> Owner VIK VL Address i001D Pa��S" <br /> Cn five, city �h"W Zip 510 i Phone# <br /> C-57 Contractor W 1 1,l 1 vA Address -jgDh MLIA 1-- L k#—_City-6&W_ka_ZIp Lic# 7* Phone//#�� D7 4771 <br /> Consultant 15ub Cntr E Address 6tp City�. Lic#�Phone# l_[_ttt 7-ln�L <br /> GIS Coordinates:X Y ,Township : Range Section <br /> WORK TO BE PERFORMED: <br /> "EW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") d DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> WELL# 0 PRESSURE GROUT <br /> 0'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MEONITORING W-1OLLOW STEM DEA,OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 2. <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS ID TYPE OF CASING: A STEEL XPVC p OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL "'�D I TREMIE TYPE TO BE USED: 0 AUGERS NOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED:- 0 Yes 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Po�-l4W <br /> 0 OTHER:_I]OTHER APPROX.BORING DEPTH _,10? It�w, <br /> H BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED jao `(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 /> 1 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 ri11e1Company �Q�[I(�j� �tl �.�ifot�a�L <br /> Print Name 4JJaale <br /> 5- <br /> 'DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: AA <br /> Application Accepted By "v Date Issued 2� <br /> Area <br /> Grout Inspection By Date Final Inspection By U Date <br /> Destruction inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ' ACCOUNTING ONLY: AID# FACS <br /> PE CODES FEE INFO AMOUNT.REMITTED CHECK# REC` DATE PERMIT/SERVICE REQUEST# INVOICE <br /> d 22 z S R# <br /> C-57_ WC--WAIVER— C-57 letter of Authoriz i o sign permit -Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/17!04 <br />