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FILE COPY <br /> San Joaquin County <br /> Environmental Health Department SITE <br /> ` 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd SITE <br /> a{ UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED CV �� <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is mancompance with San <br /> Joaq n County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELI Location zY_� �L,rt K'fooOIL ^•ross StreelAfdiK,/Z(- City S cV uw� Zip °1`i Loo sessors <br /> �/y <br /> PROPERTY. �• n n� ,'_ / D , <br /> Owner -- / G4k4ddress P16 Al, 6VICity yc c1-f- Zip .-. Phone# pr <br /> C•57 Contractor AddresyV'/1iL. <br /> Phon <br /> Consultant/Sub Cntr­UgL Address_kcM 10 Olji City So.cka Lic# Phane#��Ilo) 84'S - iT•lb '�H <br /> GIS Coordinates:XY—, <br /> Township Range Section 3o(s <br /> WORK TO BE PERFORMED, <br /> p NEW WELL f BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') g DESTRUCTION (choose type below) <br /> Q OI # E.BORING# <br /> SOIL \ OVER-BORDIAMETER <br /> n'Otbec ��iW/--1 0 PRESSURE GROUT <br /> GROUT SPECIFICA IONS <br /> COMMENTS: M1 I. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPEC (CATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS g MULTI-LEVEL WELL CASING DIA:_2- <br /> 0 EXTRACTION u AIR HAMMER/DRIVEN CASING THICKNESS- TYPE OF CASING: 0 STEELVC Q OTHER: <br /> 0 VAPOR 8 MUD ROTARY DEPTH OF GROUT SEAL-2,gI bio TREMIE TYPE TO BE U AUGERS HOSE <br /> Q AIR SPARGE/OZONE u PUSH POINT(GP or CPT)GROUT SEAL PUMPED: g Yes g No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> II SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS <br /> 17 OTHER: BOTHER APPROX.BORING DEPTH So 75 Q BOLTED TRAFFIC BOX or g STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: •c4.e - �\ - > 0.— C, � <br /> 1 <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 '�vw� Yr� Title/Company <br /> 3!m4 r4 SCi.¢.•rJr; �_t�Ill. <br /> Print Name ••T Ov�. v��=t Date_ (p` Llrrl Ob <br /> DEPARTMENT/FUSE ONLY 2 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: is (p <br /> Application Accepted By d —//-440.(7 Area OO&40 <br /> Date Issued <br /> Grout Inspection By ale Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> WACCOUNTINGONLY: AID# <br /> FAC# <br /> FEEINFO AMOUNT'REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> �8' SR#C -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc E Oro-moo/Gc <br /> EHD29-02-00I - �- <br /> 622/04 <br />