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a?1/v • San Joaquin County <br /> z' Environmental Health Department-"'­- <br /> 304 <br /> epartment SITE <br /> MITIGATION <br /> N { 304 East Weber Avenue, 3rd Floor, Stockton,CA.- 1 1 j <br /> � . <br /> (209)468-3449 Fax: (209)468-3433 Web: www,sjgov.org/eF1'dt1 UNIT IV <br /> e.� �P;'0 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 /> Assessors <br /> WELL Location tjqq`J '` Q ` ross Street to Zv City LS(14 /0-) Zip ` S3W <br /> Parcel# ZOS <br /> PROPERTYFr' <br /> ^ L > ] ! µ,1 M Cit S 1 <br /> Owner t r'-0f J� /l1 /-IA�dresrrs / }1/1p( d I y C� 6►'\ Zip 53�y2 Phone# ) 5Y00 <br /> C-57 Contractor f (�^ �S�Address ISO �00e- �d City 4'rt�K Zi .53 Lic#�/C Phone# <br /> C-- /Str�rttr ,ied ��e, 4j Address EZZ � oy� 5�. Cityl(3�I Lic# Phone# /l/S-2It3- 2tS-0 <br /> GIS Coordinates:X 'I Z I . O LN s ,Y 3-7, 90 16 Township T 1 ,S Range 1'`g Section 3 6 <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/ BORING ( P )eE6Pf296 ,HYDROPUNCH,H,'cPiB i'tIJGEiR, :FHEW) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# – C►°T- 0 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 :-�n 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:------ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS k � TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL SO \('L7 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: yAYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING0 HAND AUGER GROUT SPECIFICATIONS /IJPr� ate,­r <br /> `.OTHER: C PT 0 OTHER APPROX.BORING DEPTH 9 D -F C 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE I <br /> CONDUCTOR CASING PROPOSED It/Q (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 Ordi ces Ru s and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company Geologist/Kenned /Jenks Consultants Inc. <br /> Print Name Mike McLeod, P.G. Date `r t s �'d, <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: a kb CC) ( 4 - f2 i-• 12.O <br /> WORK PLAN DATED: `�}' `SLC-Z <br /> Application Accepted BDate Issued 1 Area <br /> Grout Inspection By Date Final Inspection By w""A� Date l L <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# 4 <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C)'Cl0 (,t S R# Lj 0j Lf 5 <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 />