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� - <br /> S � Q� <br /> E <br /> an Joaquin County <br /> Environmental IJealth Department SITE <br /> AUG 1 3 204 <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 jjITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/M: iRQNMENT HE <br /> ACLMIT IV <br /> �`'q ••-� � 4+ <br /> tirr-r Well Permit Application PERMIT/SERVICES <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ( V .ti <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 /> �r /2� /; / ( Assessors <br /> J <br /> WELL Location 19 f�1!'1L0.'a ill a- S1 Cross SVeet WPI�ls`�� City Zip Parcet# <br /> Owne PRPEl !5� ffVji(JWddress 1(o 172&)L�h1 $•I'- City Zip 1_5�Dt/ Phone# /� /� / z <br /> C-57 Contractor ((JO I Address 310 J d O r if t.'iC�lG/ti!City ,y�Lic �Wxbne# ! (� � ✓7 �11 b9 <br /> Consultant/Sub Cntr �G Address ✓ - - -� _ aty (0�oaa7Phone# �l <br /> 'J GIS Coordinates:X ,Y Township Range Section <br /> WRK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND AUGER,OTHER•) IT DESTRUCTION (choose type below) <br /> �+ 0 SOIL BORING# 11 OVER-BORE. DIAMETER <br /> WELL# I (I PRESSURE GROUT <br /> Il Other GROUT SPECIFICATIONS <br /> COMMENTS: — <br /> PE OF WELL INSTALLATICN TYPE COMSTRUCT'CN SPECIFICATIONS e-/f <br /> \ MONITORING I HOLLOW STE A DIA.OF BCREHOLE_yfQ MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING.G;A: �+ <br /> EXTRACTION /Q AIR HAMMER/DRIVEN CASING THICKNESS �'�-{ TYPE OF CASING: Q STEL PVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY - DEPTH OF GROUT SEA TREMIE TYPE TO i3 SE . UGERS D HOSE <br /> Q AIR SPARGE/OZONE Q PUSH POINT(GP or OF r)GROUT SEAL PUMPED: Q Yes o (NOTE: DEPTH IS 30')V <br /> J Q SOIL BORING HAND AUGER GROUT SPECIFICATIONS itk- 1-41L <br /> Q OTHER: D OTHER APPROX.BORING DEPTH 137y- Q BOLTS TRAFFIG(BOX or j]STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment secficn) <br /> COMMENTS: <br /> .J <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHIVIENs, PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby c iffy that I have prepared this appl' ation and that the Work will be done in accordance with San Joaquin <br /> County Ordi ances, Rules and Re io nd all applicable California State ws. <br /> Signed x Sitle/Company d <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 1&14- A) " 1410u tO <br /> WORK PLAN DATED: <br /> J Application Accepted By Date Issued + v" - _Area � <br /> Grout Inspection By Date Final Inspection tom"t"_ ate <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/SERVICE REQUEST# INVOICE <br /> Zoo 1 20 86.5 8 l3 S 3 2Z <br /> C-57 101 WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc� <br /> EM 29-02-001 <br /> 6/22/04 <br />