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ulSan Joaquin County <br /> Environmental Health Department SITE <br /> " 600 E.Main Street, Stockton,CA 95202-3029 MITIGATION <br /> (209) 468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> �_DaNO 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 Developmqnt Title, <br /> Chapter 0-1115..3 and the Standards of San Joaquin County Envvironmleental Health Department. <br /> WELL Location I�2L UT`rl f� 111AP.Cross Street c .k s�-" City <br /> r—O(i(I Zip Parcel#r <br /> PROPERTY �GCiC. 'e <br /> ( QSaYI Phone#Owner Addressyt) kx 11)-o City LoIp <br /> C-57 Contractorrfltr+S Address U12DneK City ah Zip(/WU0G381 t033Ph'oyn s6r41� <br /> 6 <br /> Consultant I Sub Cntr 11t6 �_ Address _ <br /> X3"7 S264r' CityS�Lic#j �ZPhone# o��S7 r73c� <br /> GIs Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) "DESTRUCTION (choose type below) <br /> a SOIL BORING# `OVER-BORE. DIAMETER ,l� Sr' _ <br /> a WELL# VRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS 6 <br /> COMMENTS: &'Ucr-- 0r- II I ( A� S MW - L��MU)_ 3' <br /> a Ifiw /Y -0✓0S�6ro.,1-RI( G4iPrs <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> p MONITORING a HOLLOW STEM DIA.OF BOREHOLE_ a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> li EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL g PVC a OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: O AUGERS u HOSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER:_0 OTHER APPROX.BORING DEPTH a BOLTED TRAFFIC BOX or a 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 Ordina es, Rulesand 13pgulations,and all applicable CaliforniaStateLaws. n <br /> Signed x i-�� Title/Company 1��i R/70Q l -e0I09'C�J� <br /> Print Name 'O('iAr, Mm/ha.i Date s-- � Q/0 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Ile S. <br /> WORK PLAN DATED�:I � � / a anuli 10 <br /> Application Accepted By &kik C Date Issued-qhz/o Area 997 <br /> Grout Inspection By Date Final 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 I SERVICE REQUEST# I INVOICE <br /> �D �0- (00" 311 7-0 IJX S(/(3 Io SR* 0057 SD <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001web <br /> 6/22/04 <br />