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P-in Joaquin County <br /> Envirot mental Health Department SITE <br /> { 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: wA­vv.sjgov.org/ehd UNIT IV <br /> ``p 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 /> o Assessors <br /> WELL Location 7Z 1 E l'�A� �1�<<ACross Street City S�un��(1� Zip (�Parcel# L7-3y3— o <br /> PROPERTY <br /> Owner k� Sk4� �� Address �Z� L A4✓ 4� it SIC Zip Q(�Phone# <br /> C-57 Contractor 4A C AddresslDIL6G-1C c,� CityAv,,A\AQILt.Zip 2-90 Lic#81�51j� Phone# -7[�-q1-(122I'D <br /> c" <br /> Consultant/Sub Cntr±� I i164 j JQ Address 83-7 S�,t�) 1,tA City 54 ic# (,,V()-2.-Z-7 Phone# 7-)06 <br /> GIS Coordinates: X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 'ANEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> X}WELL# ( t 0 PRESSURE GROUT <br /> O*Other O GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS , <br /> MONITORING -�B_-hIOLLOW STEM DIA. OF BOREHOLE" 0 MULTIPLE CASINGS <br /> SINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS'"-TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER. <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL —7(o TREMIE TYPE TO BE USED: IAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Wes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS V hf(0 G2,14j' 7V* -1 O (0 �kyH',,,,a tk„ -� <br /> 0 OTHER:_0 OTHER APPROX. BORING DEPTH9r . BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED /Ur, (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 Or ances, les and Regulations, and all applicable California State Laws. n <br /> Signed x �LQo �� Title/Company l <br /> 1k L <br /> Print Name \ 4t,�j l o US Date 2A'20 (12 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By /�/�C T/ d���a'f� Date Issued G-61" G o Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY AID# F <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> ! o i z 9. ' 3 F 51 C.ri7� S R# O O 1i '7 Z 9 2 <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 />