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"an Joaquin County 0 FILF <br /> Envirmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Skeckton, CA 95202 MITIGATION <br /> • (209)468-3449 Fax: (209)468-3433 Web: www.Sigov.org/ehd UNIT IV <br /> Well Permit ApplicatM AUG 17 AM 9: 43 <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 tie I`61(t@W piltation is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin ,�ir ktl fI4alth Department. <br /> Q��11 tt t. T11EN Assessors po� <br /> WELL Location 7zc) W J � • I - - . � Cross Street g Pr City T Zip Parcel# f� <br /> PROPERTY ,, ,� A'��) @ <br /> Owner (' �� ��/ Address �7� I N l�T 0 City ZipPhone# �C19' V3 <br /> C-57 Contractor RLL-C'51Qr <br /> ���Pt ddress � CiBOZipLic Phone# S70 � 45J1 # <br /> Consultant/Sub Cntr C'l� �n JK <br /> Address 110.1.���G�1 S'� S� CityAkjfjLic# Phone#�,r/O—( 3:::1P0 <br /> IZ AW" ��as o� Cl <br /> .3 <br /> GIS Coordinates:X 7,`73�3 Y ^)a).y3-78 Township �S�, h Range Section <br /> WORK TO BE PERFORMED: <br /> EW WELL/ BORING (CPT,QEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# Sb I( boa OVER-BORE. DIAMETER <br /> 0 WELL# © 0 PRESSURE GROUT <br /> 0*Other oq GROUT SPECIFICATIONS <br /> COMMENTS: �vri 7� � y7-Ld W' 9''`' XPN <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE'_25" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL—&A TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE XPUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM/,FREE/-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Tt I lv� r ` <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH Z 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED A4 (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. 1 / <br /> Signed x - — Title/Company PPo�ec� Ged09I_4 <br /> Print Name V7yyp✓� 1 V t'r\ej Date g/)0/OJ� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: Op0 0 <br /> WORK PLAN DATED: 2 oc4 <br /> Application Accepted By Date Issued Z Area a� <br /> Grout Inspection By Date Final Inspection Date l ill �O <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 2q�1 �B 8y. �8'�oR� �--I sR# <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign per Encroachmentdoc 'l <br /> EHD 29-02-001 �©✓l�. 7fv <br /> 6/22/04 <br />