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`-'an Joaquin County <br />Envi,-.,.tmental 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 />SITE <br />MITIGATION <br />UNIT IV <br />2005 SEP 13 P; l 4 35 <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This appl"C ion is made in compliance with San <br />Joaquin County Development Title, Chapter 9-1 15.3 and the Standards of San Joaquin County Environmental Health Deptnrtmemt, . `� , T Y <br />113),SIC 'IA§se�sofs.T A L <br />WELLLocation u" YT? Cross Street , C City5 / , Zip Parcel#c'' n <br />PROPERTY <br />Address PC, <o l5� _-- Cit _ Zip % Phone# / 7 U�yy�� <br />C-57 ContractbA�� G/ Address � �� Cit Zi�SZV�ic# 71 %.�4hone0b&5/1�67 <br />Consultant/ Sub Cntr Address O �J�J/ l��'` City �/�Lic# Phone# e/4"7/ l `'',f`P <br />GIS Coordinates: X , Y <br />Towns <br />Range Sectio <br />WORK TO BE PERFORMED: <br />f4EW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER`) 0 DESTRUCTION (choose type below) <br />// \\ 0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />�G ELL # -cam > 0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS' <br />MONITORING T4OLLOW STEM DIA. OF BOREHOLE [n <� MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:-!i—G— .`1_. <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL l(]�PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL/JG' �2:� TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED:.9�Ies 0 No�s/�NOT MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS /241�`L,a^ <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH /51> eOLTED TRAFFIC BOX or 0 STOVE PIPE <br />�) CONDUPTOR CASING PROPOSED (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 <br />Regulations, and all applicable California State Laws. <br />Signed x 10A- �- J`C e� Title/Company kj �, is— 6? e i� �L�d r A -(— <br />Print Name w)I I t�ezl-t, Date / —/3 <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED-: — I I I �s <br />Application Accepted By �— <br />Grout Inspection By_ <br />Destruction Inspection By <br />DEPARTMENT USE ONLY <br />&,,< 7 Wes-/- 0(�.,�� s -4- <br />.��-,nom <br />Date Issued 1 Area <br />_Date !. J inal Inspection By Date �• <br />Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT R�ll11TFD <br />CHECK # <br />REC'D BY <br />DATE P!✓ ICE <br />INVOICE <br />LIV <br />C-57_ WC= WAIVER C-57 Letter of Authoriyntic�n o sign permit ncroachment doc <br />EHD 29-02-001 <br />6/22/04 <br />