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V l / L>/ LVV / null 11: 47 r'l 4V7Y00iVii Jul. G17U <br />San 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 />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />I((,IVUL/ UUL <br />SITE <br />MITIGATION <br />UNIT IV <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 <br />WELL Location 100 A%• k Aauar 4149 Cross Street city Zip 2/S Parcel# <br />PROPERTY TYNA1J_C <br />Owner S101 "o rte Address 831 PIS, C City 4&&1offe Zip 2.9 Z17.. Phone#70+--7SZ- 4'30 <br />C-57 Contractor fern ice• J4*0%%A1 x ,Address /08/ 655Q>< A11e • City rcl. CZ <br />/1 <br />ip9f8nfl Lic#ILWJ'7 Phone# 3-10-237-4x75• <br />Consultant / Sub Cnlrwtl-114 A --air( CAS, ZsFAddressjt?ZI Pa..)e i &.CitySLic# Phone#_g/&4V5.835 <br />-5PAW 300 f <br />GIS Coordinates: X , Y Township Range Section <br />WORK TO BE PERFORMED: <br />(` MW WELL / BORING(CPT EOPROBE, HYDROPUNCH, HAND -AUGER, OTHER") STRUCTION (choose type below) <br />N <br />D SOIL BORING # <br />D OVER -BORE. DIAMETER <br />o <br />D WELL# <br />CHECK # <br />PtESSURE GROUT <br />O <br />D "Other <br />o <br />/GROUT SPECIFICATIONS <br />(3`1' <br />COMMENTS: <br />IrJK <br />it Z7 # pCJ�I �� <br />Z <br />S <br />TYPE OF WEtt <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />I] MONITORING <br />D HOLLOW STEM <br />DIA. OF BOREHOLEa MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: A14- <br />D EXTRACTION <br />D AIR HAMMER/DRIVEN <br />_3" <br />CASING THICKNESS A//4" TYpE OF CASING: D STEEL D PVC D OTHER: <br />D VAPOR <br />D MUD ROTARY <br />DEPTH OF GROUT SEAL 0 —//-5"TREMIE TYPE TO BE USED: D AUGERS D HOSE <br />D AIR SPARGE/ OZONE <br />H POINT (GP or�ROUT SEAL PUMPED: D Yes D No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />TTS` <br />ROIL BORING <br />D HANDAUGER <br />GROUT SPECIFICATIONS&, jMW r#P_ ,IL A1ta010' C_P_Jti e -J7 <br />D OTHER: <br />D OTHER <br />APPROX. BORING DEPTH //.-° D BOLTED TRAFFIC BOX or D STOVE PIPE <br />CONDUCTOR CASING PROPOSED /✓/9- (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 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 . -AJC <br />Print Name Date 02 Z %,�® 7 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: /So Ni <br />WORK PLAN DATED: <br />a 19.60 <br />Application Accepted By 11:: � Date Issued _71a;7101 Area <br />Grout Inspection By - L Dat •) Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS/ CONDITIONS: CU/2 - I3 bl-rC� <br />ACCOUNTING ONLY. <br />AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PE E <br />INVOICE <br />o <br />�1 " <br />(3`1' <br />t a v <br />IrJK <br />it Z7 # pCJ�I �� <br />C-57_ WC --WAIVER <br />E ID 29-02-001 <br />6/22/04 <br />C-57 Letter of Authorization to sign permit_ r roachment doc_ <br />