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- <br /> yDPq ! o AUG 2 5 20if San Joaquin County zf4� Y <br /> . . . Environmental Health Department SITE <br /> w: ' 304 East-Veber Avenue, 3rd Floor,Stockton,CA 95202 MITIGATION <br /> `) 209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> 6•. �P V <br /> Well Permit Application <br /> ( ON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED / <br /> Application is here 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 Environmental Health Department. <br /> r Assessors <br /> WELL Location —Cross/SSttreat Ciityy/e- 9 Zip` 3J Parcelel# c,) <br /> POROePERTY /7� c�Address P1��1°✓d� City Z, ZIPL)3-/' Phone# e �drC^,� <br /> C57 Contractor /74`yAQ.,�//.e.�..-d �/ Address�r�1Qc>Jo �3 6 Cit .v /Y Zip�ic#�.e—d�r�'hon�ilor-�,S�Gi�'"/j� <br /> Consultant/Sub Cntr4K Gr//Lf`P(-�'(9�' Address -2� E PyRr«City C�Lic# Phone# yy�i3yr <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> Q NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) Q DESTRUCTION (choose type below) <br /> Q SOIL BORING# Q OVER-BORE. DIAMETER <br /> `IrWELL# Q PRESSURE GROUT <br /> Q Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPECONSTRUCTION SPECIFICATIONS <br /> �&ONITORING HOLLOW STEM DIA.OF BOREHOLE Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA:'�el_ <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS'�E/, �/d TYPE OF CASING: Q STEEL PVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL -TREMIE TYPE TO BE USED: AAUGERS Q HOSE <br /> Q AIR SPARGFJ OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Ye/ No J(NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONSA T /l-HJT—C o�J <br /> Q OTHER:_G OTHER APPROX.BORING DEPTH_,:>? I OLTED TR2AAFFI BOX 4XSTOVE PIPEZ6 <br /> CONDUCTOR CASING PROPOSED (if YES,'St 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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company /`" <br /> Print Name � <br /> Date 65 oz <br /> Y <br /> DEPARTMENT USE NLY ��DS <br /> SITE MAP IN UNIT IV FILE, ADDRESS:lj6 4V6 <br /> WORK PLAN DATED: <br /> Application Accepted By <br /> Date Issued (O V, / Area <br /> Grout Inspection By <br /> Date Final lnspeclio Dale <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 /> 12-5y h SR# 06 <br /> C-57_ WC=WAIVER_ y C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02.001 <br /> 6/22/04 <br />