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oPa�'""•:\ San Joaquin County <br /> �. <br /> NOV I ]OW1 Qonmental Health Department SITE <br /> ewlr, ,p x`04 gasfjkVlr,Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> �24 ) C(83F�4? ax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IN <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 /> c� Assessors <br /> WELL Location �b�J UUr 1'�Nx-t c..-r Cross Street 1 3� City r- c.. Zip `S 3-11, Parcel# .a 5 5— 1 O O- 0� <br /> RTY <br /> ownerEM46 �e-cGr.1 Address\bu� DIAr`h4,r,.�cr.c Cityr� Zip S 3't6q <br /> Phone# g 3 S ' 3 S �e <br /> C57 Conlractory�� Address�50 \R9vJ 4, �ot. CityY�vN��.�ati ZipaVSS3 Lic#�$516'SPhone# q-1$ 313 S&06 <br /> Consultant/ N St CityyrhAc�.SSt-3 Uc# _ Phone# ZQ9 Si.L`Il1g <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> D NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) n DE RUCTION (choose type below) <br /> SOIL BORING# $$S D OVER ORE. DIAMETER <br /> n WELL# n PRESSU GROUT <br /> n`Other GROUT SPE ICATIONS <br /> COMMENTS: 1 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS C"' <br /> D MONITORING D HOLLOW STEM DIA.OF BOREHOLE_ D MULTIPLE CASINGS n MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: n STEEL n PVC D OTHER: <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS n HOSE <br /> n AIR SPARGE/OZONE n PUSH POINT(GP or CPT)GROUT SEAL PUMPED: n Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 1 SOIL BORING D HAND AUGER GROUT SPECIFICATIONS <br /> n <br /> OTHER:_0 OTHER APPROX.BORING DEPTH D BOLTED TRAFFIC BOX or D STOVE PIPE <br /> C \n 1 �1CONDUCTOR CtNG PROPOSED (if YES,list ecificalions in comment section) <br /> COMMENTS: �.RA V"�r�C- \10�^f `-'C� $ 23 '•l� t� �1k7z-L.)'o� <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 Ordinan R 1 s tions, and all applicable California State Laws. f <br /> Signed x_ �� Title/Company <br /> rN <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: � I Ag5 o4 f A— rod( Z; elwbw rk, eJ '02 l7et O�( <br /> Application Accepted Date Issued I=Li jo e'y Area <br /> Grout Inspection By Date Final Inspection By _-_Date <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/SERVICE REQUEST# INVOICE <br /> 3Soi Sa B9.Iw d/6595 e'.Nn <br /> _ �B ,y sR# 00'{0723 <br /> C-57WC=WAIVER _ <br /> _ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />