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San Joaquin County <br /> i 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 /> Fo 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 Devetopment Title, hapter 9-1115.3 no the Standards of San Joaquin County Environmental Health Department. <br /> pp 1 II Assessors <br /> WELL Location 1 %-I �� Cross Stree (hero W City ( Zlp`f say0 Parcel#, _ <br /> PROPERTY C� <br /> Owner 1 ( Address r I p114e S city Zio 5. V Phone# 333'���73 <br /> C-57 Contractor //�� �� }e .fl 1j Address dMfC �11 nn ity M Zip-s-Y2 LiaFj38110 phone_q16 O ll6f <br /> Consultant/Sub Cntr IA& Address 077 City Uc# ? Phone# U1� 1 -ICO <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) $jrDESTRUCTION (choose a below) <br /> u SOIL BORING# 4WVER-BORE. DIAMETER 1�` <br /> u WELL# PRESSURE GROUT <br /> a*Other GROUT SP CIFICATTIONS y ) 6 ✓R5 <br /> COMMENTS: (/n J ' u (j 4LkJ- <br /> L'ek <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE_ u MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br /> a EXTRACTION u AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC a OTHER: <br /> a VAPOR u MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br /> 0 AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER u OTHER APPROX.BORING DEPTH p BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: S /T I 1 r^tr'L'P A,-e 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 Ordinances, uleegulations, and all applicable Californi Stapte�Laws. <br /> Signed x Title/Company (`��`l)�/s'�/ <br /> Pnnt Name S ( MG Date t;--Cf <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: S. C 1 Ple� <br /> WORK PLAN DATED: <br /> � �� � D s Tia 41 �/M r731010Application Accepted By N-tC�ua�K Date Issued —Area <br /> Area 9�T7 <br /> Grout Inspection By Dale Final Inspection By Date <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 I SERVICE REQUEST# INVOICE <br /> ,- 'o2- 60' 60. 31ii7 µ� ,o sR#005995! <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 web <br /> 6/22/04 <br />