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�oaq�rN,o 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 /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 11 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 fEnv_iron ental Health Department. <br /> I l 7U Parcel#rM� -IYo-�l <br /> WELL Locatlon I I L ('EO Lee I QIe Cross Street tVQtg0 11 W City <br /> Zip�— <br /> PROPERTY q� <br /> Owner MQf /P(�_—(Address 1V70/J /D fK�City �Q I p Zipa� 0Phonge# <br /> C-57 Contractor G ,Q.[_1G1r l Address C�I'1QL I`, City 1`�NGGI Zip�ZLic# N11Q Phone qt(C 635�`//6�j' <br /> Consultant/Sub Cntr I \LAG Address 237 Sit<•w CityS�lci•1 um-Phonet.�£ S//•9360 <br /> GIS Coordinates:X .Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> p WELL# > PRESSURE GROUT <br /> 3*Other n GROUT SPECIFICATIONS q4(b /ON S <br /> COMMENTS: AW 15' IAAW'16 + /ti1W 'F) 1X��2cY d— Ia1 Cane { 6pirf <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA,OF BOREHOLE_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION O AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING p HAND AUGER GROUT SPECIFICATIONS <br /> p OTHER:_0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or p 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 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County OrdinarJSes, Rul�Regulations, and all applicable Californian State Laws. <br /> Signed x Z//7 Title/Company I fQ�PSiI ONoI fhfO�OS(5�� <br /> AA r Q <br /> Print Name (`IgM1� ✓✓41� Aq cilv� Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: A? <br /> WORK PLAN DATED:: J / �S Cr✓1✓Q / <br /> Application Accepted By td ICA — ` Date Issued �, I/T//O Area 197 <br /> Grout Inspection By Date 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# RE 'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> a�j.°� foo 60 ?!//� Ll cq Iv SR# <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 />