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EC911ff AUG 3 p ZUU <br /> ''San Joaquin. County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA.95202 <br /> MITIGATION <br /> f, (209)468-3449 Fax: (209)468-3433 Web: www.sigov.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 worts described. This application is made in compliance with San <br /> Joaquin County Develgqpment Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> AsseS•�d.�..ao.\l<. acro. e.\oma <br /> WELL Location (Z-' 'ft- N-ST b"a� Cross Street City Zip Parcel#rs <br /> PROPERTY <br /> Owner C-'c o o uWtg.n Address y�S N , �1 Loc-,off S City Sl oc lC ,� Zip 9S2vZ Phone#�3 l – 9 4 l <br /> � <br /> '3 i 1 GS <br /> C-57 Contractor S S Address 22.E N c.s fiST City\N4 4 Zip Ltc#g o133`� 53 0 4 b 2 yZy <br /> Phone# q <br /> Consults t5ub�ntr.G�\ '�Lc��Cc�D;cSAddress \10k � S� City Ll�* Phone# SD-1'9 L1 ` <br /> GIS Coordinates:X Y Township___._. Range Section <br /> WORK TO BE PEREgMED. <br /> @I NEW WELL/BORING (CPT,GEOPR BE,HYDROPUNCH,HAND-AUGER,OTHER-) Q DESTRUCTION (choose type below) <br /> 11 SOIL BORING# C4 C \– `F �`k ) 1]OVER-BORE. DIAMETER <br /> a WELL# D PRESSURE GROUT <br /> ©"Other GROUT SPECIFICATIONS <br /> COMMENTS:_ Q o <br /> TYPE OF WELL INSTALLAT12N 3nE CON§1RUCT1ION SPECIFICATIONS <br /> 1]MONITORING 1]HOLLOW STEM DIA.OF BOREHOLE <br /> 1]MULTIPLECASINGS 0 MULTI-LEVEL WELL CASING DIA: _ <br /> 0 EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 1]STEEL_ U PVC a OTHER: <br /> 0 VAPOR (1 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 11 HOSE <br /> a AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes n No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> $SOIL BORING 1]HAND AUGER GROUT SPECIFICATIONS . <br /> Q OTHER:_ n OTHERAPPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 11 STOVE PIPE <br /> COMMENTS:_ <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> S..�o `,J��\L.���,� <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,Rule and ulations,and all applicable California State Laws. <br /> Signed x " Titie/Company <br /> Print Name L�� ` (Q _�` <br /> Oates <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS:_ C -3-1)/C. f lw, 3AFA G 5 <br /> WORK PLAN DATED: I I ------- <br /> Application Accepted By 1l�'W- - CZ 1j2:'h Date Issued /v�°4' j Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> [ACCOUNTING ONLY: AID# FAC# <br /> ES FEE INFO AMOUNT REMITTED CHECK# REC'D 8Y DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 0/ 7ol �� 7 ic' a��� SR# <br /> C-57..__,- WC--WAIVER C-57 Letter of Authorization to sign permit Encroachment dac_____ <br /> EHD 29-02-00 i <br /> 6/22/04 <br />