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- m an Joaqui$ o my � FILE Guill <br /> Envirmental Health epartment SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 MITIGATION <br /> Imp <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> 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 Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> /" �� "" �/� '814 <br /> j Assessors <br /> WELL Location 195 CfJwyl" �� yrY Cross Street MI SSS City Zip Assessors 9/n <br /> PROPERT�>L n <br /> Owner /W' Address m[* kor&Aa, city—&&C4, Zip19_54 Phone# 9)*K-04 52,Contractor Add�repss ��Y �j�(` city�Zip 9�S5o3 b24 <br /> Lic � i�Phone D <br /> Consultant/Sub Cntr My �iO�AIYN'D➢9"A"k3'Address $'hRW city vL Lic# 22 Phon O (� <br /> GIS Coordinates:X Y Township Range Section <br /> VKI K TOJW PERFORMED: L o <br /> ) MEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) Q DESTRUCTION oo�pe below) <br /> �a SOIL BORING# Q OVER-BOREREE . �ER---��g <br /> 0*Other $ GROUT SPEC F cAT5Ns <br /> COMMENTS: ren x E <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING OLLOW STEM DIA.OF BOREHOLE <br /> � Q MULTIPLE CASINGS Q MULTI-L �WE�_ <br /> CASING DIA: <br /> EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESSsI�TYPE OF CASING: Q STEE4�dZVC Q`OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL3!b TREMIE TYPE TO BE USED: AUGERS Q HOSE <br /> p AIR SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED. Q Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 11 SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS CI Vir <br /> O OTHER: Q OTHER APPROX.BORING DEPTH 215' BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED D (if YES,list specifications in comment section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> herebythat I have prepared this appUcation and that the work will be done in accordance with San Joaquin <br /> County O ances,R les and Regulations,and all applicable California State Laws. <br /> Signed x Title/Company fffkdisd g G1/ 4; JzA4 <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDR S: <br /> WORK PLAN DATED: AJOV 0 <br /> Application Accepted By Date IssuedZ" 7 D Area Ob <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COLIIENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# F <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 36�. 233 /-3.G sR# C9 R# <br /> C-57� WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br /> EM 29-02-001 r <br /> (✓22/04 - <br />