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WORK PLAN DATED: <br />Application Accepted By t{" <br />Grout Inspection By <br />Destruction Inspection By <br />Date Issued Pi 7 S <br />ty <br />Final Inspection By Date <br />1-/1 Zoo <br />Date ti <br />Date <br />Area e? 97 <br />an 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 />Well Permit Application <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> <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. fqcOle0 i xaol , Assessors <br />WELL Location W , V.) ,,,...„L'. , ( A—up, Cross Street tA q- ‘1 A City --, IC --e: V-V.- Zip l V -c, Parcel# <br />PROPERTY <br />Owner ?c,c „f- 4,-, Address ( \•#`• •-t4 CityCIVe tr1-4\ Zip9(18-03 Phone# (rrOc).4 <br />C57Contractorli r&Addressi,11 0 7k cl-c11 Lic,#-11511-1 Phone#(c 77. lb\ <br /> <br />-z N • t...) <br />Consultant / Sub Cntr Address 1-r '1,1..• Zrt City C r c L._ Lic#-( cic Phone# C )11 7) (C. <br /> , Township Range Section GIS Coordinates: X <br />WORK TO BE PERFORMED: <br />fkj NEW WELL / BORING (CPT GEOPROBE, HYDROPUNCH, HA D-AUGER, OTHER*) <br />*SOIL BORIN # 1- <br />ti <br />54! IS 0)(4, <br />0 DESTRUCTION (choose type below) <br />a OVER-BORE. DIAMETER <br />PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />I A-- <br />VA./ELL # <br />1] *Other <br />COMMENTS: v t „t„ <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE `Z '1 [I MULTIPLE CASINGS [I MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESSSC 11-D TYPE OF CASING: fl STEEL %PVC OTHER: <br />O MUD ROTARY DEPTH OF GROUT SEAL jeD I TREMIE TYPE TO BE USED: 0 AUGERS ;I/HOSE <br />O PUSH POINT (GP or CPT)GROUT SEAL PUMPED: ,(Yes [I No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />O HAND AUGER GROUT SPECIFICATIONS -.1- V , aix C <br />0 OTHER APPROX. BORING DEPTH 7 <' 030LTED TRAFFIC BOX or U STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comr9ent section) / <br />COMMENTS "teç : j" .,A e \111• 1 c"‹, c2 I l L 42_ <br />Icst <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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x Title/Company <br />Print Name <br /> <br />Date <br /> <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, AD RESS: <br />TYPE OF WELL <br />XMONITORING <br />0 EXTRACTION <br />O VAPOR <br />0 AIR SPARGE/ OZONE <br />0 SOIL BORING <br />O OTHER: <br />INSTALLATION TYPE <br />HOLLOW STEM <br />fl AIR HAMMER/DRIVEN <br />COMMENTS / CONDITIONS: Clikk.) C_S jitaii, <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br />d'q M e <br />/OD --- SR#uo A il, Li ,67 <br /> , <br />C-57 <br /> <br />WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit Encroachment doc <br /> <br />EHD 29-02-001 <br />6/22/04