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Or San Joaquin County <br /> '� y 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 /> L Well Permit Application <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.1he Standards of San Joaquin County Environmental Health Department. <br /> ^�� _ Assessors <br /> Cross Street do - Cit _ Zip Parcel#WELL Location {z 1 y yu <br /> I (� <br /> PROPERTY <br /> Owner -R CAD ___ Address City. Zip Phone# <br /> C-57 Contractor.L)oewo_e) b6I')wddress . ?t'a0x 3'3(a City A'ioVfti Zip `l rLic# 91631Phone# -:?o 3 q—`1"40Q <br /> Consultant Sub Cntr S _Address ZV�b d- Cw v I cityPhone# 914 `G_ — Z.'ZG { <br /> U d <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELT.l BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) AyDESTRUCTION (choose type beE ) <br /> o SOIL BORING# AVER-BORE. DIAMETER /D'� 7 f <br /> a WELL# a PRESSURE GROUT <br /> []'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> IWONITORING )G�HOLLOW STEM DIA.OF BOREHOLE 4n ri- a MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION n AIR HAMMER(DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL *QVC a OTHER: <br /> a VAPOR A MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Q AUGERS a HOSE <br /> a AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED. *$Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> C OTHER: o OTHER APPROX.BORING DEPTH. -3 VM A ePOLTED TRAFFIC BOX or p STOVE PIPE <br /> q CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: 1 �� ►.7�1�5 ZS -3� 3 `7'�� <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 and Regulations,and all applicable.California State Laws. <br /> Signed x TdlelCompany L)K S <br /> Print Name 'G - Date S 3 0/s <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, DD SS::. <br /> WORK PLAN DATED: 2 „t 2.-4 r) <br /> Application Accepted By. l�"[� �� Date issued ��I�'D Area_ <br /> Grout Inspection B Date Final Inspection By Dale <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> 4 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES 1 FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATEPERMIT!SERVICE REQUEST# INVOICE <br /> ?rC);L &4D b6w V(1 2(;1y 2(;1 �a .�r` SR# t <br /> C-57 WC__-WAIVER C-57 Letter of Authorization to sign permit—'Encroachment doc_ <br /> EHD 29-02-001 <br /> i� 6/22/04 <br />