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oPau'". c San Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue 3rd Floor Stockton CA 95202 �� _ .9 L�O� <br /> � MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.c &I} NMEN1HIcAL7f,'UNIT IV <br /> cA` P Well Permit Application PLRM1T/SERVjCE� <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 /> WELL Location 16 77 7 //,,-/4,, <br /> Cross Street L Ou(j t City 4 7,4w, Zip 5 Assessors <br /> Parce � Q, <br /> —Q S <br /> PROPERTY //�� [� / / /f <br /> Owner l 0 Address 1677 7 /17dWI���f1�A City i0 Zip S 33OPhone#o20�f- gf0 a rll <br /> C-57 Contractor <t .-1 Address /,�O &&We./ l\� cityALA,' Zip S S�Lic#0607 Phone#�2f-3� <br /> Consultant/Sub Cntr 60 tfT-#1' ej& Addres� /O(y�h ft.S„f� City//<f?o Lic# Phone# zGq—p7 S3S <br /> GIS Coordinates:X 3 7 0 Y 7ZR t o 7 Township Range // <br /> g CG r Section 31s-- <br /> WORK <br /> 1SWORK TO BE PERFORMED: <br /> '0EW WELL/BORING (CPT, EOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> (SOIL BORING# L- 0 OVER-BORE. DIAMETER <br /> ,EPWELL# G -Y Z/!- 0 PRESSURE GROUT <br /> 0*Other� GROUT SPECIFICATIONS <br /> COMMENTS: <br /> - <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 'MONITORING HOLLOW STEM DIA.OF BOREHOLE 9" 0 MULTIPLE CASINGS �r <br /> 0 MULTI-LEVEL WELL CASING DIA: o?_ <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS SG 4 VO TYPE OF CASING: 0 STEEL �VVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL > /D TREMIE TYPE TO BE USED: WAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE P15JSH POINT(GP or CPT)GROUT SEAL PUMPED: �Ples 0 No NOTE: MAXI UMFREE-FALL DEPTH IS 30') <br /> �IL BORING 0 HAND AUGER GROUT SPECIFICATIONS_ </��� /Oi�Iv,� �r/O �f� Ttr+/le- <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 3O`10 fz ,?BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (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 ave pr pared this application n hat the work will be done in accordance with San Joaquin <br /> , <br /> County Ordinan ul ns7a �ale California State Laws. <br /> Signed x Title/Company�o� �t f <i7ss fs (/< .i (J�a,•ry�j,� <br /> Print Name Lo�y�� ,/�/� �r Date �� O <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> I � <br /> Application Accepted By � ` Date Issued .1 J Area y <br /> Grout Inspection By Date Final Inspection By Date / F� <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY. AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <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 />