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JILE <br /> San Joaquin County <br /> COPY <br /> E Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 <br /> SEP 1 0 2004MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.s gov.org/ehd <br /> j. UNIT IV <br /> Well Permit Application E7 D. ;Ci- <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. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location L2 .Cross Street69,)1",', C)L -city L -Zip zY� a rcel#—C2Z p30 --5 <br /> PROPERTY � - <br /> Owner 4L S;CAC� <br /> .S. Address_ �ZO City_Skc�LA- Zip 15ZdE Phone# <br /> C-57Contractor Address ;C.09 �q i J,-y-r- 0 2-� city ZjP95Lic#6 7 Z& Phone#A.6�1— �53-7- <br /> ,79? <br /> Consultant!Sub Cntr A cg F- Address City - <br /> GIS Coordinates:X ly Township Range Section <br /> WORK TO BE PERFORMED, <br /> �rNEW WELL/BORING (CPT,GEO PROBE,HYDROPU NCH,HAND-AUGER,OTHER*) A DESTRUCTION (choose type below) <br /> a SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 1;j?YVELL# MN I - IkW 41 0 PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS' <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> *OONITORING AHOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA <br /> Q EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS ?" TYPE OFCASING; USTEEL ;01PVC a OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 21 TREMIE TYPE TO BE USED: XAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes 10�. (NOTE: MAXIMUM FREE_FALL DEPTH IS 30') <br /> 0 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS v Ajw- TAV C'114- <br /> 6 OTHER:_0 OTHER APPROX.BORING DEPTH ( 0 BOLT ED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED r10 (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 I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules d Regulations,and all applicable California State Laws. <br /> Signed x 14�� TitlelCompany at to 4F r�G <br /> Date <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS-. 120CIP2 1411, <br /> WORK PLAN DATED: <br /> Application Acrepted By Date Issue Area <br /> Grout Inspection By Date Final Inspection By 2-3-05 <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FACA <br /> PE CODES AMOUNT CHECK REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> 7;ODES I I <br /> SR# <br /> C-57_V WZ�-WAIVER C-57 Letter of Authorization to sign permit 17Encroachment doc-1W <br /> EHD 29-02-001 <br /> 6122/04 <br />