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o�.lN <br /> San Joaquin County COPT <br /> Environmental Health Departmentz, v. �_��,� SITE <br /> 600 E. Main Street, Stockton, CA 95202-30294 �S, 9 V` ITIGATION <br /> (209)4 8-3449 Fax: (209)468-3433 Web: www.sjgov or&� z <br /> ca 3 �J `i„�, UNIT IV <br /> Well Permit Application -"��. <br /> o, <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f - <br /> i <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This {iit arlon 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 /> WAY/'"� N� 1/�I( ' y r l p Q�y�Assessors <br /> WELL Location K�N��y,�� fir, p�Cross�Street �/Q •o�,l/✓�Cit�1 CJS. V�_Zi (nppsressors �� <br /> PROP <br /> Ownner(J&A1 CjM&jCjMtl)tX/Address A/ ^N7 1/W City/'I({/Tr� Zip2fl, Phone#5/D- 9 [2+� <br /> C-57 Contractor I IO W N14 Address Z� N. bait —City-44-0-444Zipg ( Lic#&2' �(Phoneek !90- 32'ZyZY <br /> Consultant/Sub Cntr �(C Addres$Z&. City Lic# Phone#TV--W--W <br /> GIS Coordinates:X37 0 YY, p'// Y-IZl 27 V3 Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/ BORING (C T4Eo�P OB HYDDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> g SOIL BORING# D a OVER-BORE. DIAMETER <br /> 6 WELL# g PRESSURE GROUT <br /> a`Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> g MONITORING a HOLLOW STEM DIA.OF BOREHOLE_ D MULTIPLE CASINGS g MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION g AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL fl PVC a OTHER: <br /> u VAPOR g MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: C AUGERS g HOSE <br /> a AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes g No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 'HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: ^7 0 OTHER APPROX.BORING DEPTH // a BOLTED 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. <br /> I hereby certify that I have <br /> ,pprepared this application and that the work will be done in accordance with San Joaquin <br /> CounZZ4 <br /> s nd Regulations, and all applicable California State Laws. <br /> Signed ��! Title/Company <br /> Print Na V Ti N �7tRJ4 Date Q 7� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDR SS: Z53Z �1`B.yx �J /'j7h t4O <br /> WORK PLAN DATED: I 200h / '— <br /> Application Accepted By Date Issued lO—2�� T Area L/�a <br /> Grout Inspection By _Date Final Inspection By Date <br /> Destruction Inspection By Dale <br /> COMMENTS/CONDITIONS: <br /> "ACCOUNTINGAID# FAC#AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR# oo51 0IVER_ C-57 Letter of Authorization to sign permit Encrnw ^m^ent doc— ✓ <br /> EHD 29-02-00]web <br /> 6/22/04 <br />