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q <br /> opSan Joaquin County <br /> Environmental Health Department <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> 11 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 the Standards of San Joaquin County Environmental Health Department. <br /> �,`� Assessors i���A <br /> WELL Locations 2- 5'Gnn I WWy Cross Street� City � Zip Parcel# -fJ G '-1( <br /> PROPERTY, <br /> UftVCWAddress V City [ <br /> C-57 Contractor L^-'t/t�i� �Q. UY`1I�� Address 3V 9 0/� WAC,,�l��C,it Zi -`� ic# phone# t� t� �C/r/"`t;(� <br /> Consultant/Sub Cntr C -. �N h� __Address (�lll PG Y 11 I►Itity Lic# Phone# I-('rl�jp-Ll/c <br /> GIS Coordinates:X� 19__ 2-! t� ,Y I�IJ I y11gD�5 ar ,Township V Range Section <br /> WORK TO BE PERFORMED: <br /> EW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> Q SOIL BORING# ®OVER-BORE. DIAMETER <br /> „WNELL# YY1) - /$ a PRESSURE GROUT <br /> ®*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS /J <br /> MONITORING ®HOLLOW STEM DIA.OF BOREHOLE II ®MULTIPLE CASINGS ®MULTI-LEVEL WELL CASING DIA: _ <br /> ®EXTRACTION ®AIR HAMMER/DRIVEN CASING THICKNESSTYPE OF CASING: a STEEL PVC ®OTHER: <br /> a VAPOR ®MUD ROTARY DEPTH OF GROUT SEAL , TREMIE TYPE TO BE USED: ®AUGERS a HOSE <br /> AIR SPARGE/OZONE ®PUSH POINT(GP or CPT)GROUT SEAL PUMPED: )(Yes ® o (NOTE: MAXIMUM FREE-FALL DEPTH IS 30' <br /> ®SOIL BORING ®HAND AUCCG,,��E,,,,R t� GROUT SPECIFICATIONS mm A �I D IT <br /> 0 OTHER: OTHER SOA 1C APPROX.BORING DEPTH ®BOLTED TRAFFIC BOX or STOVE PIPE <br /> CONDUCTOR CASING PROPOSED U (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 Ihis application and that the work will be done in accordance with San Joaquin <br /> County Ordinanc es and R fions,and all applicable California State Laws. <br /> Signed x Title/Company_CP4�Sy <br /> Print Name Date "i! ��n vn n c n t, <br /> — --�� N' <br /> ® ARTMENT USE ONLY DECEIVE® <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 2007 <br /> WORK PLAN DATED: <br /> Application A A C �eJ°.rw�Date Issued ���7 07 <br /> SA JOAQUIN COAL <br /> Grout Inspec Datd�" 7 Final Inspection By ® �°� at, j4 RTMENT <br /> Destruction Inspection By Date <br /> COMMENTS!CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> p. OT .123f9 7 /1a/®7 sR# ©D �j <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 />