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a t �� 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 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 andtheStandards of San Joaquin County Environmental Health Department. <br /> WELL Location�- /� �llcJAssessors <br /> Cross Street <br /> City ��L Zip55-3-�G Parcel# t}��♦'8'�r? � <br /> PROPERTY �1 <br /> Owner T(`�'i�i1^ Address -P0 30x �60 Cih+atA--� ZlP,9y 7Phone# 1 <br /> C-57Contract0r a r'. Address �O 336 City r� Zip, Lic# ��` Pane#_ '�3� c7 <br /> Consultant ISub Cntr (_itc Address2`�� (]rt�( 5 City�Lic# Phone#cj/6 � `i zzr,, <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED- <br /> 0 NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,'HAND-AUGER,OTHER'). DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 'lig_VER-BORE. DIAMETER <br /> n WELL# 0 PRESSURE GROUT <br /> []'Other i GROUT SPECIFICATIONS <br /> COMMENTS:_ :s�c c FA C, 1 l.'�.�`,. U3e-�l D (� � -- #rya # <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MMONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS B MULTI-LEVEL WELL CASING DIA- <br /> 0 <br /> IA0 EXTRACTION 0 AIR HAMMER/DRIVEN CASfNG THICKNESS TYPE OF CASING: B STEEL- 0 PVC BOTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: . 0 AUGERS p HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED. 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:. Il OTHER APPROX.BORING DEPTH ]]BOLTED TRAFFIC BOX or'n 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 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinanc Rule Regulations,and all applicable California State Laws. Trot <br /> Signed x Title/Company Com? t5 C,IQ i <br /> ' Print Name V V l 1 Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE DDR SS: <br /> WORK PLAN DATED: Z� 240 <br /> / � Area-g9� - <br /> Application Accepted By bd Date Issued <br /> Grout Inspection By- Date ?____Final Inspection By Date <br /> Destruction Inspection By Date 2. DS <br /> 1 <br /> COMMENTS 1 CONDITIONS: <br /> [ACCOUNTING ONLY: AID# FAC# <br /> E CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> Z �D �� ���7 � � ESR#4;a�/V737 <br /> C-57 wc -warvE+z C-57 Letter of Authorization to.sign permit`Encroachment doc� <br /> EHD 29-02-001 <br /> 6122/04 <br />