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U <br />San Joaquin County V,�o% <br />Environmental Health Depard' <br />304 East Weber Avenue, 3rd Floor, Stockton, CA1 �- <br />(209) 468-3449 Fax: (209) 468-3433 Web: R�«v.sjgov.fV_$tl <br />Well Permit Application s <br />SITE <br />MITIGATION <br />UNIT IV <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />PE CODES <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 />CHECK # REC'D BY <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />INVOICE <br />Z3 \ S st Assessors <br />WELL Location N . l D o� o �� Cross Street �S j i� Cit �� _t_ -, Zip clS Lo"{ Parcel# 1 � 5 - 1 0 0 - 1 � <br />;3; `7.� <br />PROPERTY 11 <br />Qwner '� direr Uc�,lc4,r - Address b L3 L HQn.Q-E krP— CityS'ToclC Qr� Zip I SS20 ( Phone# LOcl <br />n 4J V , (J '•� y <br />C-57 Contractor V a D \\ Address Q �' f `i \fin Cit 5�4 1�� 7J �S `i� LJ <br />Y P Lint` Phone#�•`� <br />nsuita V Sath-Cntr_ c9 9— `fie d1, c�'Address_ '7 1 S\ City o a Lic# Phone# S 2Z i 11 <br />GIS Coordinates: X 'Y Township Range Section <br />WORK TO BE PERFORMED: <br />g NEW WELL/ BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') U DESTRUCTION (choose type below) <br />a SOIL BORING # p OVER -BORE. DIAMETER <br />Q WELL# �l)_ $5;,W .- 2 a PRESSURE GROUT <br />`Other <br />Q GROUT SPECIFICATIONS_ <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />a MONITORING i HOLLOW STEM DIA. OF BOREHOLE Q MULTIPLE CASINGS n MULTI-LEVEL WELL CASING DIA: _ <br />A EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: o STEEL 17 PVC 0 OTHER: <br />Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEALh Z' - Ste., �'y, TREMIE TYPE TO BE USED: a AUGERS a HOSE <br />a AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />(a SOIL BORING it HAND AUGER GROUT SPECIFICATIONS <br />a OTHER:_0 OTHER APPROX. BORING DEPTH�BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />O <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />` <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 Ordina 7cies nd g tions, and all applicable California. State Laws, Q y—� z <br />Signed x �--� Title/Company 2A t ; Com. cv� > 11 <br />ll 1 n:C vq�i <br />Print Name 2��o� �o� A c\a �- Date I Z9 / S <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By k Date Issued ", Area <br />Grout Inspection By Date Final Inspection By Date <br />Destruction Insoectio <br />COMMENTS / CONDITIO <br />Date '. <br />ACCOUNTING ONLY: AlD# FAC# <br />PE CODES <br />FEE;NFO AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE PERMIT / SERVItf_R_l5CrUEaT # <br />INVOICE <br />)-Oi <br />;3; `7.� <br />1 6i3 <br />n 4J V , (J '•� y <br />C-57� WC -WAIVER C-57 Letter of Authorization( j/o sigh permit c_ <br />EETD 29-02-001 <br />6/22/04 <br />