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San Joaquin County > n er <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.sjgov.org/ehd UNIT IV <br /> Ak Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED FILt UUPY <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 /> J 20 unt Dellopment Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> cc..�s JAssessors <br /> W L Loca' �� Cross Street n ��;n AY. City h Zip 53G�Parcel#Zb1D�I Z <br /> PROPETY <br /> Owner=p. A'�� Address 1W hAQ/��'L0&- CityS*)C�Zip �0 Phone# (00 _ SD <br /> C-57 Contractor I Address 15b / k4 Ki1> City_/ Zip-'?j50�`Lic#�j�one# r�� �d0 <br /> Consultant/Sub Cntr Address��Ils St• *.4 City Lic# /7QStJ G.Phone#5-14yWW <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED- <br /> EW WELL/BORINGCPT(EOPROBE, YDROPUNCH,HAND-AUGER,OTHER*) Q DESTRUCTION (choose type below) <br /> ` OIL BORING# Q OVER-BORE. DIAMETER <br /> Q WELL# Q PRESSURE GROUT <br /> Q*Other GROUT SPECIFICATIONS <br /> COMMENTS L aPT b06ftS A19 7 "Whil- b9 • <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING Q HOLLOW STEM DIA.OF BOREHOLE Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL Q PVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> Q AIR SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS <br /> Q OTHER: Q OTHER APPROX.BORING DEPTH Q BOLTED TRAFFIC BOX or Q 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 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Or ina ces, Rules and Regulations,and all applicable California State Laws. <br /> Signed x Title/Company S'•]j S 4x* �� f /CQ1,/ %114 n�-� <br /> Print Name &t �- 2_ Date Ir// <br /> DEPARTMENTUSE ONLY — , <br /> SITE MAP IN UNIT IV FILE,ADDRESS: _ )0.2--9- rro72 a-'A <br /> WORK PLAN DATED: -7/.25I O G " t?/ a7/ 0 <br /> Application Accepted By )h6+01-1119 Date Issued 67 Area , yv <br /> Grout Inspection By ����.1r, �?i/�Cf.4gDate )-(-1-3(0 Final Inspection B� , ` cLe /S <br /> Destruction Inspection By ( Date <br /> COMMENTS/CONDITIONS: b 2 a <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 35_3 '285- 374; 0d SR# 6)04qe 4,.6 <br /> C-57_ W(--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />