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San Joaquin County <br /> a Enviamental 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 /> Well Permit Application 2001 FEB 30 PH 12: 07 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 5 A N <br /> Rl�Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. ThisJt�a@AA84 Is�ey�NT AL <br /> irTWrppj�nce with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin unty Environmental Hc��(tIartment. <br /> Cross Street "' ty� `'"�Zip 5203 Parcel#Assessors _�D <br /> WELL Location 3 <br /> PROPER 1f j n[ /1 <br /> Owner i.J �e {/ O �/Address !/03 1 - l GLz City Zip J �/��Phone# �7 / <br /> C-57 Contract 6/�+i1 ddress �/✓�C-� r city�Zip k7q4ic#7�7S��Phone# /l(�3�� ��4� <br /> Consultant/Sub Cntr TfC7 Address S2 S .1,1 Pl city s V4)Lic# Phone# 1 bo <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> �gNEW WELL/ BORING (CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> XWELL# 1:-LJ 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING iOLLOW STEM DIA.OF BOREHOLE /0)lvt MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: ' <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL `PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL y© r'P2� TREMIE TYPE TO BE USED: jy'XUGERS 'HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_0 OTHER APPROX. BORING DEPTH BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> _ 14Je f CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br /> COMMENTS: �k 1 y�LC�(,(� r <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, Rules and Regulations, and all applicable California State Laws. <br /> Signed x ,h { Title/Company 196-2 C2 <br /> Print Name / Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 174'6 (,J Lon (e D,,,. to <br /> WORK PLAN DATED: /z L/5-1Z ,a L, <br /> Application Accepted BDate Issued 3 �3/G Area i <br /> Grout Inspection By Date D Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> W SR# 04 '99� �- <br /> C-57., 1WC=WAIVER_ C-57 Letter of Authorization to sign permit-ZEncroochment doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />