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San Joaquin ounty <br /> Environmental Heal th Department W (° SITE <br /> 304 East Weber Avenue, 3rd FI r, Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax:(209)468-343 Web: www.sjg0v.org/ehd AUG 3 Q 2dU4LJNIT IV <br /> IFOR Well Permit Ap lication ENVIRONNIEN <br /> NON-REFUNDABLE PERMIT EXPIRES'I YEAR FROM DATE ISSUED PERMIT/SERVUS <br /> Application is hereby made to San Joaquin County for a permit to construct an /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 Say Joaquin County Environmental Health Department. <br /> �yt Assessors�/�1 -t <br /> WELL Location/�/f/i/s/Ile7]Jr. ilic_Cross Stree City S}a-ktnse ZiPffParcel#1V--2.2 — �T <br /> PROPERTYPhone# <br /> Owned-�• f'1Faeul•i LPAddress Ci,�.�.=a.F- <br /> C-67 Contractor ctts,&d-k/ Address City Zi�p1 C�cP1 TSI C Phone# -_ <br /> Consultant I Sub CntrC"T/C, ;Lgdd>e01dtLq,_Address" City Dsu Phone#%, 5-� <br /> GIS Coordinates:X C) Y (J ,Township2 Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> a SOIL BORING# a OVER-BORE. DIAMETER <br /> `WELL#{3At&---Smt �w�I %3t/ �)01 s II PRESSURE GROUT <br /> a`Other G GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS Iy <br /> a MONITORING HOLLOW STEM DIA.OF BOREHOLE_ MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:AtTEEL a PVC a OTHER: <br /> Q VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS NOSE <br /> XAIR SPARGE/OZONE O PUSH POINT(GP or CPT)GROUT SEAL PUMPED: X'Yes I7 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 11 OTHER: _�OTHER APPROX.BORING DEPTH X TED TRAFFIC BOX or 0 STOVE PIPE <br /> � t <br /> CONDUCTOR CASING PROPOSED ND (it YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCES$ AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOI ICE? 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, Rules aqd R ulations, and all applicable California State Laws. 4-1 <br /> Signed x TnIe/Company S✓ t eel W-57 071C � .'< -�`s'•� <br /> Print Named-i' �" •"' e'�� On Date <br /> DEPARTM , T USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> � � ,j� <br /> Application Accepted By <br /> I' ` Date Issued n Area9"/? <br /> Grout Inspection By Date'/ 2, o Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# =AC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# EC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> SR#��,�03 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22104 <br />