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6'04. E GUY Y � <br /> man Joaquin bounty <br /> Environmental Health Department AUG 4 TE <br /> MITIGATION <br /> ��. 344 East Weber Avenue, 3rd Floor, Stockton, CA 95202 Z <br /> (249)468-3449 Fax: (209)468-3433 Web: wm,w.sjgov.org/AuVIP,ovotiv NIT IV <br /> PERMl7jSRl H <br /> Well Permit ApplicationR <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FRO A DATE ISSUED <br /> Application pis hereby made to San Joaquin County for a permit to construct and/or install tht work described. This application is made in compliace withwith San <br /> Joaquin County Development <br /> Title,Chapter 9-1115.3 and the Standards of San Joaquin Co my Environmental)Health Department. <br /> ssessoWELL Location ��� '�� � �� 57, _Cross Street /[�1� ity 5ra-,0T�/v Zip�arcel#rs��� <br /> PROPS-71BBr 3 � !! <br /> Owner- ��V�111 � � ddress ACO2.N S T. cit)S zi1,�2�`Pnone# <br /> 7 `' i <br /> C-57 Contractor �i F/ cG/elite Address !�46Address City tie ip9y 3 ic#jS JPhone# g 3,3 � <br /> Consuita Ii I Sub Cntr /L A",-e. Address A ity�brtic#A_7Q Z Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> . <br /> WORK TO;i <br /> BE PERFORMED: <br /> EW W,Ei_i_!BORING (CPT,GEOP OBE,HYDROPUNCH,HAND-AUGER,OT ER*) ,DESTRUCTION (choose type below) <br /> SOIL BORING# A n OVER-BORE. DIAMETER <br /> p WELL# 71 Z72 V PRESSURE GROUT <br /> n`Other GROUT SPECIFICATIONS _ <br /> COMMENTS: _ I <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> )(MONITORING n HOLLOW STEM DIA.OF BOREHOLE�_ n MU TIPLE CASINGS n MULTI-LEVEL WELL CASING DIA:.... . <br /> I]EXTRACTION n AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL []PVC�Ia OTHER: <br /> n VAPOR�i n MUD ROTARY DEPTH OF GROUT SEAL FULL TREMIE TYPE TO BE USED: ,AUGERS a HOSE <br /> I]AIR SPARGE!OZONE PUSH POINT(GP of GROUT SEAL PUMPED: n Yes No (NOTE: MAXIMUM FREE-&L DEPTH IS 30 <br /> l]SOIL BORING n HAND AUGER GROUT SPECIFICATIONS /O <br /> I]OTHER:) n OTHER APPROX.BORING DEPTH ZS e n BOLTED TRAFFIC BOX or n STOVE PIPE � <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications In comment section) <br /> COMMENTS: 72Te'-'reo A <br /> �I <br /> NOTIE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 5 4$WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I herebycertify that I have prepared this application and that the wor c will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations,and all applicable Califo nia State Laws. <br /> Signed x TillelCompan <br /> i�. �l G f�G Date <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: AA <br /> WORK P�LAN DATED: <br /> Application;Accepted By Dat Issued_ ��� �P Area <br /> Grout Inspection By Date Final Inspection By <br /> Destruction Inspection By Date <br /> i <br /> COMMENTS I CONDITIONS: <br /> L <br /> I <br /> ACCOUNTING-ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY onper <br /> PERMIT I SERVICE REQUESTS INVOICE <br /> .S50 t sR#C-57 WC -WAIVER C-57 Letter of Authorization to smit_Enc ro ent doc_ <br /> BHD 29-02=041 <br /> 6122/04 000 / <br />