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� ! • San Joaquin County <br /> 'i <br /> z: z Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 <br /> MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> °Q4/fi0, Well Permit Application <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 /> jAssessors <br /> WELL Location 2 I b ��W Z n Cross Street J �J City t-5CA Zip S326 Parcel# 7 X06-_ <br /> c <br /> OwnnerEC�[ iQ Il.� Q C.�D•, J.A—ddress � YS rvw� City l f SPS Zip IS/3,D Phone# Za•'.�38' <br /> C-57 Contractor l7/tPact �f �I`" Y 16CAddress �+� //'0)e ��. City�drt'� ezZip g7�Lic# 6 Phone# �ZS-3J3� -y CO <br /> Consultant/Sub Cntr f�/'e�q✓avL k5 Address 6 Z Z�vj5�S t �sCity_�� Linc#4 Phone# %,S-Z-Y3 'Z/.S 0 <br /> GIS Coordinates:dinates:X 7�, ��/�'�.Y 3 J. �O 16 Township T J Range Section .3 { <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING CPT, EOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# Cr,I 3 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 /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLEZ-,y 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:------ <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS_TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 53 t1 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE YIPUSH POINT(GP or CPT�GROUT SEAL PUMPED: A Y'e'ss/ 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 1v2U-i C'4,1 . <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH So -F&• 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED )I ��_(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 Ord' ances, Rules an>Regulations, and all applicable California State Laws. <br /> Signed xAg&� <br /> Title/Company Geologist/Kennedy/Jenks Consultants Inc. <br /> Print Name Mike McLeod, P.G. Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 0R k-66 l S 4-• ZL 12 0 <br /> WORK PLAN DATED: '� 06 <br /> Application Accepted By Date Issued 1 ! °I �0 Area <br /> Grout Inspection By__l �� Date 1/2410-4- Final Inspection By (AAAMov_ Date O <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> E�= FAC# I <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> U9.00 l ��6 G,{ ( Iq/off SR 4c( S <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />