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AUG 3 p `lUt1 <br /> -PLT `f an Joaquin. County <br /> Environmental Health Department SITE <br /> a ! 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/ehd UNIT IV <br /> 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 Develqqpment Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health DepartmentAssessors <br /> WELL Location C�a,'C e a- �v.�oc a� ) Cross Street City S o�1CAo ZIP <br /> PROPERTY S} S'T p1i6+4 9SZvZ <br /> Owner-C--\N h o S}o v�Lac or Address ya" N , to l�oc 14° CitY •� Zip GS <br /> ne# <br /> ^\ 3 1-1 cOl Zip Uc#%oa 33`{Phone# 5 3 0 b$ Zy Z`� <br /> C-57 Contractor QS S Address ZZ o ,�u S'1 City\No q--- <br /> Gonsuita tSab-entr G i SAddress l\O\ -1S� CityM��' U,* Phone# Salt't1 1 <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> d NEW WELL 1 BORING (CPT,GEOPRQBE,HYDROPUNCH,HAND-AUGER,OTHER") a DESTRUCTION (choose type below) <br /> 6 SOIL BORING# C4� \— `� `f ) ]]OVER-BORE. DIAMETER <br /> 0 WELL# Q PRESSURE GROUT <br /> 0`Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INS16LLATION 3nE C0Nfi'RUCTION SPECIFICATIONS <br /> a MONITORING Q HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _ <br /> a EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: d STEEL a PVC Q OTHER: <br /> 11 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br /> a AIR SPARGE/OZONE »PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes d No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> #SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: fl OTHER APPROX.BORING DEPTH a BOLTED TRAFFIC BOX or d STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (ifYES,list specifications in comment section) <br /> COMMENTS: c\L��\3�- a -e 3-2-'Os <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 O nances,Rulej and Regulations,and all applicable California State Laws. <br /> Signed x " Tifle/Company !�t ,�rs� . <br /> Print Name 6. 6�' _ Date <br /> v DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 3J�ZG 5 <br /> WORK PLAN DATED: // �/ <br /> Application Accepted By ,fl.///s;/ .,.C'`,cid'c`� Date Issued _ 0 9 Ale ,,, OS Area �Yf 3 <br /> Grout Inspection By Date Finai Inspection By Date <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 1 SERVICE REQUEST# INVOICE <br /> 0 SR# 00 q'i 76 3 <br /> C-57____ WC—,,,`-WAIVER C-57 Letter of Authorization to sign permit__-_Encroachment doc____ <br /> EHD 29-02-W I <br /> 6/22/04 <br />