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` San Joaquin County <br /> P <br /> Environmental Health Department ENVIRUNMITIGATION <br /> a ! 304 East Weber Avenue,3rd Floor,Stockton,CA 95202 <br /> 468-3449 Fax:(209)468-3433 Web:www.sjg0v.org/ehd PERM1P'-I(JNi f iV <br /> v1l� <br /> • S�/FORS` Well Permit Application D , <br /> O <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 /> ssessors Gi <br /> yco luso Lam...c <br /> Cross Street Ci AC- Zip 1Parcel# <br /> WELL Location. ""_ • C14. <1+ <br /> PROPERTY (7Of <br /> R,7 4 > k1.�oGJ Address lG7�S S.L1o.4anc� City1Fzip4533U Phone# 3-SSyZ <br /> Owner t� - <br /> C-57ConVactoS•-I '.`.( Vr:IJLr•n�:. Address �So Zr�c:- 21. )) City�°L)'' a Zip-�_Lic# 1 Pnone 1Aig6I <br /> jb <br /> Consultant/Sub CnV . <br /> S^' - �-+^* ^L- Address 3a�7-lam /'o cf <br /> IYl l4Cfly L"1o'n Uc# Phone#1�/ �t�C -c�'{Du <br /> GIS Coordinates:X <br /> Y.,Township Range Section <br /> WORK TO BE PERFORMED: - <br /> "EW WELL I BORING ( PT,GEOPROSE,HYDROPUNCH,HAND-Fi -`-R,OT4ER') OVER BDI <br /> AMETER_ <br /> (choo type below) <br /> g:SOIL BORING# - - 1]PRESSURE GROUT <br /> SWELL# �/ '�t']l—t -- /' Q GROUT SPECIFICATIONS <br /> — <br /> a <br /> COMMENTS r - <br /> TYPE OF WELL INSTALLATION TYPE \ CONSTRUCTION SPECIFICATIONS 1z: <br /> AMONITORING E'JiOLLOW STEM,ueel`} DIA.OF BOREHOLE S 11 MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA; <br /> 0 EXTRACTION- O AIR HAMMER/DRIVEN CASING THICKNESS 5rL- 1­40 TYPE OF CASING: 0 STEEL S;PVC Il OTHER: <br /> 0 VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL 'V TREMIE TYPE TO BE USED: 0 AUGERS *HOSE <br /> S AIR SPARGE/OZONE SPUSH POINT(C of'GFT)GROUT SEAL PUMPED: 0 Yes S'Ido (NOTE: MAXIMUS FREE-FALL DEPTH IS 30') <br /> ''SOIL BORING 0 HAND AUGER , ) GROUT SPECIFICATIONS �z'-'+ �"C""-' <br /> a OTHER: U OTHER APPROXI BORING DEPTH Z S� VOLTED TRAFFIC BOX or STOVEPIPE. <br /> CONDUCTOR CASING PRgOPOSED (If.­_,YESlist specifications in commentsection) <br /> COMMENTS: For ( t) �.„ t'�,..�,r-t�r. ,g. 1..'s <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 Ordinan as Rules and Regulations,and all applicable California State Laws. <br /> �� � �� $c� �•�+�SF Lipa? .Lrf. <br /> Sgnedx ��" �- Title/Company ` <br /> Date <br /> Print Name /�o- ^'Q-`•J <br /> DEPARTMENT USE ONLY ' <br /> SITE MAP-IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: ' <br /> Date Issued d=wArep <br /> Application Accepted By <br /> Grout Inspection By Date Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK* REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> f U�U p 3 y 11) SR# 00 D�3Z <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to Sign permit_Encroachment doc �y� <br /> EHD 29-02-001 - <br /> 6/22/04 <br />