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San Joaquin County <br /> z o� Environmental Health Department SITE <br /> N �< 304 East Weber Avenue, 3rd Floor, Stockt in, CA 95242 <br /> MITIGATION <br /> ' (209)468-3449 Fax: (209)468-3433 Web: .sjgov.org/ehd 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 andfor 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. 1 <br /> tt Assessors <br /> WELL location 3c15 .w S+_ Cross Street r~�d� St. iiy_�c�fOAt Zip `lS�b� Parcel# <br /> PROPERTY ,n <br /> Owner 1 Y.rrj JVrr 1��w �� _Address 3y� 7a�erZ City a Zip q lcs _Phone# 70 (P�- ZZ�� <br /> C-57 Contractor �1 - re ;- Address S�na Cit c Zip�j_�Lic#6.9 2 Phone#/(ZCQ X16'7-(_UOG <br /> Consultant!Sub Cntr ptG —Address—S3'71S&L, (2-�,. City Lic#/,,Z2- Phone# 1 Z6`jam �/bar-LGCsC� <br /> GES Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> pWEW WELL/BORING (CPT,GEOPROBE, HYDROPIUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> OIL BORING Q OVER-BORE. DIAMETER I <br /> a WELL# a PRESSURE GROUT <br /> 0"Other c I GROUT SPECIFICATIONS <br /> COMMENTS: iNx tit 's a QST �7r v <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATI NS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE 2'r d M LTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS NIA TYPE OF CASING: 0 STEEL U PVC 17 OTHER: <br /> (a VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL 8,1 +i cf- TREMIE TYPE TO BE USED: D AUGERS [I-HOSE <br /> AIR SPARGE!OZONE elru-SH POINT(0or CPT)GROUT SEAL PUMPED: p Yes E to (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> eSOIL BORING a HAND AUGER GROUT SPECIFICATIONS rk laKdceme.4 <br /> i <br /> Q OTHER: (1 OTHER APPROX,BORING DEPTH Q BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED 1A (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGRE MENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIR D FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that thework will be done in accordance with San Joaquin <br /> County Ordinances, Rules and gulations, and all applicable California State PLla+ws. n <br /> Signed x TitlelCompa y Sf��t ' } n`t,5+ AC E- <br /> Print N e Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> ri <br /> Application Accepted By D to issued I 1� Are <br /> Grout Inspection By Date Final Inspection By • Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AiD# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATEPERMIT!SERVICE REQUEST# INVOICE <br /> �s of x-79- 3�$°9 a�oSS Or- D� SR#005 6135. <br /> C-57— WC--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc— <br /> EMD 29-02-001 <br /> 6122/04 <br />