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°'•""\ San Joaquin County <br /> is Enviesmental Health Department 4,'% 2 5 2006 SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 9MITIGATION <br /> (209)468-3449 Fax: (209) 468-3433 Web: www.sjgov.tt,1,*N,'4ENT HEALTH aLTN, UNIT IV <br /> Well Permit Application ERVICES <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 Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> r /- Assessors <br /> WELL Location_ (Cn>DC` 1nj , [1;,f{b, ( c,,4 M-CrossStreet ;aPNr �c)- cityS+cc {r,� Zip 5TH o Parcel# — I <br /> PROPERTY � <br /> Owner Mc_in S,4,.� „�_�. Address 293>0 \�rrb,11L,,,L City Mere t- Zip.j535Q Phone#_4 {;) q 3 <br /> C-57Contractor r�,'fr � a-f); 1:�y Address ALItle _City ''.r-e. ZipjL;52 Lic#ts7z4}7Phone# 'lt/y`90110 <br /> Consultant/Sub Cntr Address 35-'1 ��.a sl City SrrrLfv L Lic#_C2gC,2 z'T Phone#�zna�Y�7 Jac <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED; <br /> EW WELL 1 BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) p DESTRUCTION (choose type below) <br /> ©SOIL BORING# 0 OVER-BORE. DIAMETER Q <br /> frVVELL# 'u,- - }t - _ Of n PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: C <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING +B' 01-LOW STEM DEA. OF BOREHOLE__SL 0 MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA; 2� r <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS_!c-, r) TYPE OF CASING: a STEEL {j"FVC a OTHER: r <br /> D VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL tL�' Li,(- TREMIE TYPE TO BE USED: ©AUGERS7ff<OSE _ <br /> a AIR SPARGE/OZONE ©PUSH POINT(GP or CPT)GROUT SEAL PUMPED: des p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') O <br /> a SOIL BORING p HANDAUGER GROUT SPECIFICATIONS�..25' <br /> Q <br /> ©OTHER; OTHER APPROX. BORING DEPTH_ 5 r 55 _R-SSLTED 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. �7 <br /> 1 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. nn - <br /> Signed Title/Company s' �� ,s+ A(YY <br /> Print are e' tiu ,� Date — ST- <br /> el r- <br /> DEPARTMENT USE ONLY (1 <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued_ O eI 16/f 0{P Area <br /> Grout Inspection By e, f/ Date '? 117 Final Inspection By __r2Z dr _Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# F <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3 s 0 `r z 7 3G� 2 z 3 s" C. ij� 7 zs a� S R# Q o 4 7 s 7 4 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />