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�oPgU i. �o San Joaquin ounty <br /> Envii#mental 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 ft <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED m flov 10 PM t, <br /> Application is hereby made to San Joaquin County for a permit to construct and or install the work described. This ajj6'%tio'R90)spp Mlg�4l)Cg with San <br /> Joaquin County Development Title,Chapter 9-111155.3 and the Standards of San Joaquin County Env�ironmmentarl,HealtFF b�r4'W014HE NT AL <br /> WELL Location IIaOI Tiwn VI � �`- S'LNT <br /> HHl <br /> Cross Street n City Zip Parcel# <br /> PROPERT'A�/.� !/�, m , (as <br /> Owner NI �I/; F�l,'✓Qn Address l rU� V City O S Zip hone# /�Y /��p // <br /> C-57 ContractotCd�[I? Address 36� O ' � City ��7�h �LidF�l7�Phone#-Lt7`0.5 0�/NfJ <br /> Consultant Sub Cntr `) Address�'7 S CityJc# Phone# 0 �o <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ISN W WELL/BORING (CPT,GEOPROBE, HYDROPUNC D GLIM p DESTRUCTION (choose type below) <br /> SOIL BORING# s `"{� Y a OVER-BORE. DIAMETER <br /> Q WELL# �" u u' I]PRESSURE GROUT <br /> Q`Other 99 � GROUT SPECIFICATIONS <br /> COMMENTS: l�itiJ �I rs ( Q h ' -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SP CIFICATIONS ).✓i�(i <br /> ONITORING �(-IOLLOW STEM DIA. OF BOREHOLE +� MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: '_ <br /> Q TRACTION Q AIR HAMMER DRIVEN CASING THICKNESS TYPE Op CASING: Q STEEL JJ fSVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL J & EMIE TYPE TO BE USED: "UGERS Q HOSE <br /> Q AIR SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Oyes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS D��I _nA <br /> Q OTHER:_G OTHER APPROX. BORING DEPTH <br /> x -�J Q BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> ._ CONDUCTOR CASIN 3 PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: �� G✓IS <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 /Orrfr(oinaDnces, Ru/lsees a t egulations, and all applicable California Sit/ate Laws. L <br /> Signed !/ I Q �I�I Title/Company r/�'/6�: <br /> Print Name Date <br /> DEPARTME14T USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: l0 1 n Rj�- <br /> WORK PLAN DATED: b <br /> U u•y? G 1454 <br /> Application Accepted By V i C4oY' Mt Date Issued /C- 13 -06 Area <br /> Grout Inspection By Vf&}yr�'a !tADate -L -t7 Final Inspection By Lll a?'�rJ6.ry1 s��gG-0ate 1��2 B•OL <br /> Destruction Inspection By / Date <br /> COMMENTS lCONDITIONS: KS I SrL r ^ <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# EC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> 3503 �.67 r BS 312 74 sR# pp488G7 <br /> C-57_ WC--WAIVER— C-57 Letter of Authoriz tion to sign permit_Encroachment doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />