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FILE COPY <br /> 0441"vv. <br /> San Joaquin County <br /> Environmental Health Department ('i' SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd DEC 1 0 ANIT IV <br /> Well Permit Application ENVIRONf;�r,T HEALIt{ v+v <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMITiSERV;CFS <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 /> Assessors <br /> WELLLocatlon R11(l1G7-O 6�— c`, e�6{' _Cross StreeTett�- xCity 4L4,— Zip �151 Parcel# <br /> PROPEP^ 7S, &y(d CitY� Zhone# <br /> d� ft� <br /> .. - <br /> Owner !� V 11 t, <br /> C-57 Contractor <br /> I�Gvr�rr9�-,Cr1 V:,I�, Address sS0 r�'.�e.t' r —CIty�J L(:`• 1 Zip�/�l LIc#71110-ei Phon 3�4-1(3 <br /> Consultant/Sub Cnlr` - - 7 -"1 _:Ec)( dress 3a _\r�• /axity _Lill Phone# f/r�lr:�rol <br /> GIS Coordinates:X - ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 1KNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') g DESTRUCTION (choose type below) <br /> OIL BORING# 11 OVER-BORE. DIAMETER <br /> DWELL# n PRESSURE GROUT <br /> E•Other lam"'� � GROUT SPECIFICATIONS -- <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> n MONITORING 1]HOLLOW STEM DIA OF BOREHOLE 1_S n MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> g EXTRACTION 13 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 1]STEEL D PVC U OTHER: <br /> g VAPOR p MUD ROTA DEPTH OF AGROUT PSEAL <br /> IO TREMIE TYPE TO BE USED: D AUGERS $'HOSE <br /> �AIR SPARGFJ OZONE USH POI (GP rCPT)GROUT SEAL PUMPED: $Nes O No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> IKSOIL BORING AND AUG GROUT SPECIFICATIONS ��'�-'+ L _ '--""- <br /> a OTHER: n OTHER - APPROX.BORING DEPTH n BOLTED TRAFFIC BOX or U STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ord!np �s,,1�Rpr�ules and Regulations,and all applicable California State Laws. <br /> Signed x Title/Company S'�-(�F 'c""� `5�` <br /> /✓1 4Iz Date 17 -c-c�`1 <br /> Print Name �k> �� `n <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: !�— <br /> WORKPLAN DATED: — -0 <br /> Application Accepted By Date Issued �-- ea �� S <br /> Grout Inspection By <br /> Date Final Inspection By �"—_ �Z$-Q <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 35o s fit- (ao 2�3 -la sR# p p 33 <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />