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,San Jot;quin County <br /> Envi�'�'� mental Health Department <br /> 1� i <br /> SITE <br /> { 304 East 1eber Avenue, 3rd Floor, Stockton, CA 95 wE <br /> ITIGATION <br /> (209)468-3449 Fax: (209)468- i Web: www.sjgov. UNIT IV <br /> c,Fp� Well'Permit ApplicMionAIJt; 9 2005 <br /> NON-REFUNDABLE PERMIT EXPIRES I.YEAR FROM DATE IST <br /> QNNME V ��rr <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work describ � i he in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115..3 and the Standards of San Joaquin County En'vironm� � ttYy 1n �t. <br /> �af, L-4-11122 C1 6 I Cross Street City !I Zi qOv Parcel#Assessor -3)- <br /> WELL Location Y � P <br /> PROPER ff /� ` D <br /> Owner D i0 Address f''1� 00 1 4W-Cit)�f`uP Zipq _Phone# /�f6�/ <br /> C-57 Contractor D i Address36� 0*$C.,_Cf) _City V1 o Zip 57 Lic#?M,9 Phone Ifa '39- l # <br /> Consultant I Sub Cntrk-c __Address skaw 01 City Phon,&aj WC�) <br /> GIS Coordinates:X Y Township I Range Section <br /> `f <br /> W RK TO BE PERFORMED: <br /> I <br /> EW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER*)i p DESTRUCTION (choose type below) <br /> II SOIL BORING# a OVER-BORE. DIAMETER <br /> Q WELL# l W-2 CNA-? l VKW-4e ) KA 0-9 a PRESSURE GROUT <br /> p*Other (,,(9 GROUT SPECIFICATIONS <br /> COMMENTS: <br /> IIJ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS { 1( <br /> MONITORING O1-LOW STEM DIA.OF BOREHOLE p MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:1_ <br /> it <br /> a EXTRACTION 0 Alli HAMMERIDRIVEN CASING THICKNESS.5CLI 40 TYPE OF CASING: a STEEL )ePVC 0 OTHER: <br /> a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL(a0l 11 TREMIE TYPE TO BE USED; ,'SAUGERS 1]HOSE <br /> a AIR SPARGE!OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ` Yes p No I(NOT : MAXIMUM 1FREE-FALL DEPTH IS 30') <br /> a SOIL BORING la HAND AUGER GROUT SPECIFICATIONS 5i <br /> a OTHER:_D OTHER APPROX,BORING DEPTH S ,1 BOLTED TRAFFIC BOX or ©STOVE PIPE <br /> CONDUCTOR CASING PROPOSED I� :!� (if YES,list specifications in comment section) <br /> COMMENTS: I� ; <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. i <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. I <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 any Regulations, and all applicable California State Lws. _ D <br /> I <br /> Signed x Title/Company i O <br /> Print Name T40� 1 I k Date D 5 <br /> DEPARTMENT USE ONLY <br /> k <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATEQ: ps I I I <br /> 3 <br /> Application Accepted ByDate Issued $ z_ O — Area <br /> Grout inspection By I , l tin Date -9 300 S- Final Inspections By O 4 Date <br /> Destruction Inspection By _ Date <br /> COMMENTS 1 CONDITIONS: <br /> I <br /> ACCOUNTING ONLY: AID# FAC# a I I <br /> i <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 3�s`! a 5 Uo 36�•�e� Z�Yz G<.� $'lla5 S R# 36�S10 <br /> C-57-._, WC -WAIVER C-57 Letter of Authorization to sign per, Encroachment doc <br /> EHD 29-02-001 <br /> ` 6122104 I <br />