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San Joaquin County <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 /> 9�rFOR�' Well Permit Applicationito <br /> � A ` <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. Thi U pll nce with San <br /> Joaquin County Development Title, <br /> Chapter 9/-1115.3 and the Standards of San Joaquin County Environmental H Mel o a <br /> WELL Location/Q)17 � / ( f i d—C Cross Street City S�l� Zip /, +�4 Parcel# s O <br /> PROPE TY I r5_451 —,fLo I <br /> Owner k,94V;'-' /r�.oJSe'r Address�G33� 94c- C L City •ST/L Zip9,�CaPhone# . <br /> C-57 Contractor'4r,e- Address S3? City S'T K Zip`/S)SLic#6MW Phone# 'IG7 '/C <br /> Consultant/Sub Cntr ,46F_ Address X37 Sl,�� City STw Lic�'Y0-2r1-7 Phone#Ct(,'7 `/CO�- <br /> GIs Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> O EW WELL/BORING rr•.(CPT, PROS HYDROPUNCH,HAND-AUGER,OTHER-) p DESTRUCTION (choose type below) <br /> L@4SOIL BORING# 10 a OVER-BORE. DIAMETER <br /> 0 WELL# a PRESSURE GROUT <br /> a"Other GROUT SPECIFICATIONS <br /> COMMENTS:�C P ,LIUU ESTI G-aT=ON <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE I•I Z5 0 MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA:_ <br /> 0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS fV 4 TYPE OF CASING: O STEEL O PVC BOTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL N Ak TREMIE TYPE TO BE USED: GAUGERS a HOSE <br /> a AIR SPARGE/OZONE -PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes f a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> /V <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS A <br /> D.OTHER: 0 OTHER APPROX.BORING DEPTH I—( BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED /V/I' (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 ce at I have repared this application and that the work will be done in accordance with San Joaquin <br /> County O ces, Ru an s, and all applicable California State /Laws. <br /> Signed x � i� Title/Company_ G�/7� 'go C— / (' E <br /> Print Nam f���<< / ' C r Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: I Z)-�'I C <br /> WORK PLAN DATED: a.S s <br /> Application Accepted By Date Issued Are ` Z <br /> Grout Inspection By Date Final Inspection By Date tri <br /> Destruction Inspection By 0 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 /> P01 0S (f ';Lg l 1 41463 QS S R# 4// 3 7 <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 />