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o�q"'" tan Joaquin County • Y <br /> �o <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> -3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> Well Permit Application <br /> G ,NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 6r-F. <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 /> /� *T <br /> ^ Assessors <br /> WELL Location Z6�5'7 S• [�,,.r -a. ttA . Cross Street Ore* + L;,L City �/���Zip"17530 Parcel# Z�- oo7o�-o4 <br /> PROPERTY U <br /> Owner Grl An pQ}7iw; 1 ",*AR Address Po$ex ]�o.sr� Ci+City zip SJ'7$ Phone# <br /> C-57 Contractor r eSOhM.:�JOY��L Address220 tJ. G^^a1S- 3 . City VVDpAZip 17 i 5';I Phone# ZgZ <br /> Consultant/Sub Cntr ,$fN— Address3900&),& A*5%W City S+sJwHe.A:feic# NA Phone# jK 793723 <br /> GIS Coordinates:X ,Y Township 25 Range Section .3S <br /> WORK TO BE PERFORMED: <br /> +XNEW WELL/ BORING (CPT, GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER-) p DESTRUCTION (choose type below) <br /> �SOIL BORING# 6.1-0 6_2� 6-Sj G.4-I .Gg-Z/Lg'3 •D OVER-BORE. DIAMETER <br /> WELL# 0 PRESSURE GROUT _ <br /> 0`Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE V 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:Rh- <br /> -0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NR TYPE OF CASING: p STEEL 0 PVC 0 OTHER: t4P( <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 2S ' TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br /> 0 AIR SPARGE/OZONE PUSH POINT GP r CPT)GROUT SEAL PUMPED: 0 Yes )(No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 'SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS AjaA*- <2PV.#L+ <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH LS 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED W Ac (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 /> Signedx ( dJ•4 )./`-� Title/Company Qnpj u�'t 6tA t SA--0, tl 7/c�� <br /> Print Name I l�;d[� 01.•0! QN b- Date I Z-i3'a4 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: l <br /> WORK PLAN DATED: Z2r lea <br /> Application Accepted By Date Issued / <br /> W Area 46 F T� <br /> Grout Inspection B � <br /> y Date l- 'd Final Inspection By Date <br /> r� <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE I <br /> 290E IV3 gya sR# D® D bl <br /> C-57_ WC -WAIVER— C-57 Letter of Authorization to sign permit_Enepeechrts'nt doc_p�y�c Q� <br /> EHD 29-02-001 <br /> 6/22/04 <br />