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o Aq�IN'.,c San Joaquin County 0 <br /> Environmental Health Departm �'j S�/�j; SITE <br /> 304 East Weber Avenue,3rd Floor,Stockton,CAS F� TIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.one1 X03' UNIT IV <br /> Q<rFWell 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 9-1116.3 and the Standards of San Joaquin County Environmental HE alth Department. <br /> Assessors <br /> WELL Location 17.80 11110- W es r) ' ,�A cross Street A•1 P 1 n e CityS !N Zip Cj Parcel#J 4�,�Qlt_�)45 <br /> PROPERTY Am�2.r/ccLv1 M"1 drnyy (' J <br /> Owner ►n r 11j,r«h (Ef.Q.Addreis&i?Q��O t� "I'LL City ' v Zip �7 0:Fho�3 <br /> C-57 Contractor P re c 16 0 n Address- CityZips/ LidlN.lLlc/ Phone# S%O .l� •45 <br /> A s <br /> Consultant I Sub CntrI r/1n I A c l l•�• Address 4 4 L, l 611 City A f44�ro.Lic# � Phone#-2L?—2y 33-. ou <br /> GIS Coordinates*X'Ir3�I �-r l ,Y > - Yb� Township 1/ Range Section 143 <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DEST UCTION (choose type below) <br /> a SOIL BORING# a OVER-BORE. DIAMETER <br /> a WELL# a PRESS JRE GROUT <br /> '•Other _ nr G4i -r IS: tL / GROUT PECIFICATIONS <br /> COMMENTS: nle ✓er5 T Ui- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE_ fl MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASIN : Il STEEL 0 PVC 0 OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE E TO BE USED: GAUGERS a HOSE <br /> a AIR SPARGE1 OZONE a PUSH POINT(GP orCPT)GROUT SEAL PUMPED: 0 Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING aHAND AUGER GROUT SPECIFICATIONS <br /> JOTHER.! G C OTHER 0.a It- Pv(YAPPROX.BORING DEPTH 19— a.J 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> .7"�— CONDUCTOR CASING PROPOSED NO f YES,list specifications in comment section) <br /> COMMENTS: d- UPan. V .at4rcc <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 it accordance with San Joaquin <br /> County Ordinances, Rules and Regulations,and all applicable California State Laws <br /> Signed x "'- � Title/Company -�-Q rlI L /' +'y G�1 t L,I <i .t- <br /> Print Name Garth Date l 1/a (1 J <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: / ,1 <br /> Application Accepted By �� Date Issued ! r /0 5 Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: JAIDOO FAC# <br /> PECODES FEEINFOAMUNTREMITTED CHECK# RECD BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 110 I L I ? . 00 13 IS3 0 VSR" 4 -- 72- <br /> C-57_ WC=WAIVER_ C-57 Letter of AuthtT� <br /> ignpermit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />