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.Ian Joaquin County ORIMM <br />Environmental Health Department p SITE <br />600 E. Main Street, Stockton, CA 95202-3029 � �-E(! `,.MITIGATION <br />ll <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV <br />Well Permit Application APP - 7 <br />NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISg11ECNv1R0N&1f� <br />p ' HcALTr1 <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. -d- compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />/� , _L c? ''��++ __ ,,vv Assessors . <br />WELL Location ��� AV&- —Cross <br />Street ct� City`,�'r'��t Zip`1�2t) 2 -Parcel# <br />OwOnerER t i -J�C Addres � ZipS—Phone# J71 8339 <br />C-57 Contracto ; �Address3Z ()neC a'%- $Cit$^"f"ipL*2Cic#-1►75l0Phone#"1'0- 308-1(q <br />ii// �7 <br />Consultant/ Sub Cntr U Addrese) , 0 W g City�Lic# Phone# `,,l[ I 1 q)(,o 00 <br />GIS Coordinates: <br />WORK TO BE PERFORMED: <br />�I—EW WELL / BORING <br />0 SOIL BORING # _ <br />WELL # <br />*Other <br />COMMENTS: <br />Township, <br />(CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />Range Section <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS n <br />MONITORING J'I-IOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA. ---- <br />a <br />—_0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL a PVC a OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL25' ItC)"F7 REMIE TYPE TO BE USED: ,B AUGERS 0 HOSE <br />g' <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 9Yes 0 No ( OTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH IZD C4� BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />��// ,� \ CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: M I n S V\L(J� 4 <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 w w�"1"'�� �t C1�/ Title/Company � t0 <br />Print Name'v i I,�.'A R Date J 3 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 3 0,9 onr-}'h GrQri 4- Sire e+ <br />WORK PLAN DATED: Fe, brLk a r-,/ 28, 10 t) fi y,'/ -9-d P <br />Application Accepted BV j cin,-; a L 0- f4A r 4w?k _Date Issued 4-01-019 Area <br />Grout Inspection By Y'ithria L,1jf.&r+VLfj4j Date Final Inspection By Viej&rfd (. Mt,64rM!!1 ;Date 5-- 2- -0S <br />Destruction Inspection By Datryte <br />COMMENTS / CONDITIONS: SVV OT <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / S EST # INVOICE <br />3501q3S03 <br />,e . <br />.0 <br />At 3293, 0 0 <br />213 0'7 <br />dim <br />4-4 -D8 <br />S 00S <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit_ Enc meat doc_ <br />EHD 29-02-001 web <br />6/22/04 <br />