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• FILE COPY <br /> San Joaquin County <br /> Environmental Health Department Aaov SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.orglehd VIP UNIT IV <br /> 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 /> /I ,1 Assessors <br /> WELL Loratlon qOy °�'+^I,c� �r Cross Street �'�' h` ?✓L City j+"cK�"' ZIP'�SZo7 Parcel# 11 1300 <br /> PROP'""'SG.yrt <br /> owns, Addresa/01y�✓ n�y.,L,E.t D� CRY-.j46'(_10- Lptis'Zo7 Pnone# zoq-y?Y-Ydyd <br /> csTcontamor� -.f(i __Addressy3-P q0111(- <br /> Consultant <br /> cr✓cConsultant I Sub Cmr_EN'S 2 (,,-,tip 4rr+, Amress io-f y cry Pr,.y, y city .K.,a. Uca P6 G.�b I Phone*q 1 3 6 L'7IaO <br /> GIS Coordinates:X ,Y ,TownsMp Range Section <br /> WORK TO BE PERFORMED: <br /> D NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH.HAND-AUGER,OTHER-) XDESTRUCTION (choose type below) <br /> OIL BORING# D OVER-BORE. DIAMETER <br /> 'IYVELL# 1l. 'PRESSURE GROUT <br /> -Other 'GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> XWONITORING 0 HOLLOW STEM DW OF BOREHOLECC" D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA Z_3�S <br /> D EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS O I 94 TYPE OF CASING: D STEEL A`PVC 0 OTHER: <br /> D VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 4f S 74. TREMIE TYPE TO BE USED: D AUGERS 0 HOSE <br /> D AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: D Yea D No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> D SOIL BORING D HAND AUGER GROUT SPECIFICATIONS <br /> D OTHER: 0 OTHER APPROX.BORING DEPTH 6% Ff 'BOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (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 Ordinances, Ryles a/Id Regulations,and all applicable California State Laws. <br /> Signed x `-- /,SCA - /i ��1,.'✓9/ TdIUCompany <br /> m �NJ l C <br /> Print Nae rL 5,'�t L'( Dale i��Y�(J 7 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADD ESS: j a0 $b OO C✓Q u/t /✓ S/ 19 S� <br /> WORK PLAN DATED: / <br /> Application Accepled By Date Issued me nArea V s <br /> Grout Inspection By Date Final Inspection e <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTINGONLY: AID# FAG# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKS REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> �Dy 16 SR# <br /> C-57_ WC_WAIVER_ C-57 Letter of Authorization to sign permit_En _ ch�m-e_n't doc— / <br /> EHD 29-02-001 n�// ✓ <br /> 6/22/04 V!� <br /> f� <br />