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1 tM. C <br />Signed x <br />' Print Name <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 /> <br />County Ordinances, Rules ad Regulations, and all applicable California State Laws. • <br />Title/Company 5ar 6,,11,7t /AG <br /> <br />Date ci • 9 <br />DEPARTMENT USE ONLY <br />/?83Y <br />/3/ .2-co <br />Final Inspection V •ic:a Date 3 2_3, <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />Date Issue <br />Date <br />Date <br />TYPE OF WELL <br />AMONITORING <br />0 EXTRACTION <br />fl VAPOR <br />fl AIR SPARGEJ OZONE <br />a SOIL BORING <br />fl OTHER: QOTHER APPROX. BORING DEPTH 15 <br />INSTALLATION TYPE <br />AHOLLOW STEM <br />a AIR HAMMER/DRIVEN <br />a MUD ROTARY <br />O PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes <br />O HAND AUGER GROUT SPECIFICATIONS fe,c a <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE R 4 ' a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS 2 TYPE OF CASING: 0 STEEL $PVC U OTHER: <br />DEPTH OF GROUT SEAL 2 TREMIE TYPE TO BE USED: XAUGERS fl HOSE <br />(NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />:315_ <br />( a BOLTED TRAFFIC BOX or a STOVE PIPE <br />(if YES, list specifications in comment section) CONDUCTOR CASING PROPOSED <br />4e)/' <br />orci Area <br />---,-,t,c v'E, <br />Environmental Health Department <br />ORIGINAL rn) <br /> <br />SITE= , _ <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 sEp 10 . .- 2004MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT iv <br />HIVIKuNiVIEN I HEALI H Well Permit Application PERMIT/SERVICES <br />San Joaquin County <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. <br />WELL Location I 17.:'"CaSel l,\) , 01'4 v..Y,/ )2_ Cross Street 6-)co,5c4c lc City 1:. c., . <br />,.., <br />Zip ct$Z <br />Assessors <br />LIC, Parcel# (..)25- C3) <br />PROPERTY (Lr te 7,,Co <br />Owner Address '-d,b,c.,C) City Etx.L Po.4. Zip `15-ZdE Phone# <br />C-57 Contractor A4( [411 2r,/ld Address $ C-4:.11 Ali 1 ctic• \\y. City t',..vcx. Zip q..5-112 Lic;#67Z6I7 Phone* ic,-(e31- 3s1?1 <br />Consultant / Sub Cntr A (4 E_ Address 33.-i.---Je..,3 gc.,. City ,1-c(1:40...t- Licit oc227 Phone* ZC39- tiVi -I co co <br />GIS Coordinates: X , Y Township Range Section <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') a DESTRUCTION (choose type below) <br />a SOIL BORING # a OVER-BORE. DIAMETER <br />gWELL # Aktns I - (14V4 q a PRESSURE GROUT <br />El *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PE: - - : flUEST # . INVOICE <br />O/, 40 '5?1, c71(0 2.2_ C14. F-io s R# 00597147 <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit VEncroaChment doc <br /> <br />EHD 29-02-001 <br />6/22/04