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l� San Joaquin County <br /> li <br /> Environmental Health Department <br /> A 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 UNIT IV <br /> Q�rxoWell 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 /> p r� �p �{ Assessors <br /> WELL Location <br /> 2,2� `J S�. 1tt. IZ� Cross Street�tWc4—%.A- City F-SCIL Zip `552-0 Parcel# ZOS»26O-tg <br /> PROPERTY ZtL.OR� S'C P-tC (20 EsCr4 6y.%, Zi �PhonGe <br /> Owner Se CQ •n V t T Address p / City p p r� <br /> `I N 1 1 C s{�'1k�dress 1 sU r10 W� City R ifs 4Z ZiojgS 3Lic#yob Phone# 1 �3�3�`�0�� <br /> C-57 Contractor��/< <• <br /> Consultant/Sub Cntr 1<0-H K J&►1 I;S _Address 6 Z2 �.10►r Sfi City a N Lic# u Phone# �1 f�Zy.7'Z sO <br /> I to ,16 <br /> GIS Coordinates:X`ILI Z 11145 ,Y ? It 2-37 Township 1 t J Range 1\ E Section 3 <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/ BORINGCP GE P OBE, YDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# G� "' (�C�T'Z 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 BOREHOLE_2�-Ll% 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:______ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS N R TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> VAPOR MUD ROTARY DEPTH OF GROUT SEAL O� TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE VUSH POINT(GP or CPT)GROUT SEAL PUMPED: &'Y.e1s 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS )JCaI.X llj 4 f' <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 'W a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED N (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 and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company Geolo ist/Kenned /Jenks Consultants Inc. <br /> Print Name <br /> Mike McLeod, P.G. Date 4 Z Ol <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: Z l `Sd If f S f-- 2--f-- 12-y <br /> WORK PLAN DATED: 45T <br /> X5 (06 <br /> Application Accepted By WaXA CCNI, Date Issued V l Area <br /> Grout Inspection By Date Final Inspection By Date 2 `� <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> 1 <br /> ACCOUNTING ONLY: AID# FAC# 4 <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 00 r ��►�1�� SR# C1 Ll s Z <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 />