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. .� ..a... FILE COPY f <br /> San Joaquin County <br /> 2�E py Environmental Health Dep rtment SITE <br /> 304 East Weber Avenue 3rd Floor, Stockton, CA 95202 <br /> ' MITIGATION <br /> • :. "• {209)468-3449 Fax: (209)468-3433 Web: wm'w.sjgov.org/ehd UNIT IV <br /> �� lyaP Well Permit Application <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 /> i <br /> ��i/V (ii�l/'U/�/�//� Cross Street r//�fT ty Jr�x.�T�N Zip Parcel#rs 5- pow <br /> WELL Location_ i n <br /> 1� 7 �T <br /> PROPEF'" r f� '"/QP i <br /> Owner r Address r7 - ���� Zip` Phone � �� 'j�y3 <br /> C-57 Contractor r_f rv� Address Dom! City ,v ip9�s�3 Lic#6 �7Phone#p /2�� 3 S�pf <br /> Consultant/Sub Cntr/2�`1/G L I!rVV4 f'- Address Z ily�(�Lic# ff 77110 Phone# 71j 77i 9��T <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TOIBE PERFORMED: - <br /> NEW W LL/BORING {CPT GE PROBE HYDROPUNCH,HAND-AUGER,OT ER') ,DESTRUCTION (choose type below) <br /> JSOIL BORING# G' d []2VER-BORE. DIAMETER <br /> -0 WELL# -Sj PRESSURE GROUT - <br /> a*Other "GROUT SPECIFICATIONS <br /> COMMENTS: - <br /> � I <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING a HOLLOW STEM DIA.OF BOREHOLE Z []MU TIPLE CASINGS 4 MULTI-LEVEL WELL CASING DIA: <br /> h <br /> 13 EXTRACTION n AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: d STEEL (I PVC a OTHER: <br /> [I VAPOR } MUD ROTARY DEPTH OF GROUT SEAL fiX-L 1� TREMIE TYPE TO BE USED: )(AUGERS p HOSE <br /> AIR SPARGE!OZONE PUSH POINT(GP o CP )GROUT SEAL PUMPED: p Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30 ) <br /> 0 SOIL BORING p HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:] n OTHER APPROX.BORING DEPTH ! p BOLTED TRAFFIC BOX or p STOVE PIPE <br /> � ? ���� CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: [ I�w6k? Ae <br /> L / /(J K, <br /> •I Z3lt .�/r �ip�!/�iZi?�/A �i� T <br /> NOTIE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> i <br /> I hereby.Icertify that I have prepared this application and that the wor will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable Califo nia State Laws. <br /> Signed x !� .� , rr Ivy _ _-._TitlelCompan r <br /> Print Name !' Date -'SCO <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADD S <br /> i <br /> WORK PLAN DATED: !9 G �a b b / `,/, <br /> ApplicationAcceptedBy Dat Issued l (% Area ©(Q. <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> IN <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY ATE PERMIT f SERVICE REQUEST# INVOICE <br /> C-57 0 WC _-WAIVER_ C-57 Letter of Authorization to si n permit Encroachment doc <br /> EHD 29-02-001 <br /> 6122104 <br />