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U1 ro 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 <br /> UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 7 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,iChapter 9-1111}5.3 and the Standards of Sari Joaquin County Environmental Health Department. <br /> �'1�� f+L+�T..��.s'1_Y1!'f� rr r PaSe Ona rr__ <br /> WELL Location Cross Street t�l��ll City 1 Zip `�S Paroel# ZT <br /> PROPE TY <br /> Owner { Address City Zip Phone# C <br /> C-57'Contractor 1� ``F I Address ?DX. 53(f City. v 1 Zip Llc#sit Phone# 7J•-�"x}36 0 <br /> Consultant 1 Sub CntrL} Ci Address 10 ic# Phone* 'fib 6?'� Z26 1 <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> U NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER•) (DESTRUCTION (choose type below) <br /> U SOIL BORING# P9:0 -BORE. DIAMETER IC) <br /> a WELL# U PRESSURE GROUT <br /> U"Other GROUT SPECIFICATIONS <br /> COMMENTS' C5 <br /> � fx <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> DCMONITORING U HOLLOW STEM DIA.OF BOREHOLE U MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA" <br /> U EXTRACTION U AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL a PVC U OTHER: <br /> Il VAPOR U MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: U AUGERS U HOSE <br /> U AIR SPARGE]OZONE U PUSH POINT(GP or CPT)GROUT SEAL PUMPED: U Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> U SOIL BORING U HAND AUGER GROUT SPECIFICATIONS <br /> U OTHER:. J]OTHER APPROX.BORING DEPTH ll BOLTED TRAFFIC BOX or U STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (it 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 havere ared this application and that the work <br /> p p pp will be done in'accordance with S n J a uin <br /> County Ordinan es, ules nd R tions,and all applicable California State Laws. (' n t'- f}?LL� <br /> Signed x (1-. <br /> tie/company l0f S Q <br /> Print Name_ 1't 1�G . <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: 27bD <br /> Application <br /> Accepted BY Date Issued <br /> t Grout Inspection By Date F' at Inspection By Date <br /> Destruction inspection By Date Q <br /> l COMMENTS f CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 3 So-z- e0SR# d0 <br /> �z-3 CQ <br /> C-57_ WC,.—WAIVER„_, C-57 Letter of Authorization to sign permit`Encroachment do'c <br /> EHD 29-02-001 <br /> 6/22/04 <br />