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} <br /> t Joaquin County <br /> ; nvironmental Health Department SITE <br /> L��a <br /> 600 E. Main Street, Stockton, CA 95202-3029 MITIGATION <br /> 468-3449 Fax: (209) 468-3433 Web: www.sjgov..org/ehd <br /> \�y 02 2 u UNIT IV <br /> o� <br /> Well Permit Application <br /> EP IR0i%TfAE NT HEA-1 H <br /> PERIV: RVI N-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor 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 /> i, �r Assessors <br /> WELL Location 'ss� 5. F!/�rL- cs!O S1Cross Street /._qi -City Zip y- Parcel# /67-67001-03 <br /> PROPER . <br /> owne — Address <br /> 7 �56>St/ A._ o f <br /> n �� rn� Address PGe �5'` City .�„ q'z p KQLic#7 4 hone#gI� 990 �. <br /> C-57 Contractor �l/�rSS _ Qr 33 <br /> Consultant I Sub Cntr 16012/a6 itZl_y Z,ac: Address 100 16 5,r9 _ _city n-194�c#P��1�47 Phone# C116 �jGITJ 033� <br /> GIS Coordinales:X Y Township Range Section <br /> WORK TO BE P&BFORMEt]_ <br /> �'�NE`i`J=WEi:L`l-BOFZING=(Cr T;GEGPRDSE HYD�OPJ1��F,-FitiND-Ai7GEPC;OTHER")"-"= DESTRUCT ION (ohoose type beiow)Y-- <br /> Q SOIL BORING# 0 OVER-BORE. DIAMETER <br /> a WELL# $PRESSURE GROUT <br /> a'Other GROUT SPECIFICATIONS <br /> i COMMENTS: <br />�I <br /> I TYPE OF WELL iNSTALLAT-ION TYPE CONSTRUCTION SPECIFICATIONS <br /> ItMONITORING n HOLLOW STEM DIA.OF BOREHOLE .0 MULTIPLE CASINGS p MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION n AIR HAMMERIDRIVEN CASING THICKNESS_4irk14Q TYPE OF CAS]NG: p STEEL ;.PVC a OTHER: <br /> f 0 VAPOR p MUD ROTARY" ° DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: A AUGERS M HOSE_ <br /> Q AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> G SOIL BORING- _ D HAND AUGER GROUT SPECIFICATIONS <br /> i a OTHER: Q OTHER APPROX.BORING DEPTH z a BOLTED TRAFFIC,BOX, or Q STOVE PIPE 4^ _ <br /> CONDUCTOR CASING PROPOSED &A (if YES,list specifications in comment section) <br /> COMMENTS' _ h " <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work-will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x !]Y�t ,f'V J Title/Company /3G+ 6 K -e?7 "r- -f7 ZSOQ �2_ <br />!f+ Print Name_�L^y /__ <br /> k DEPARTMENT USE ONLY <br /> ' � ``'' r <br /> SITE MAP IN UNIT IV FILE A DRESS:_y�,�.&2� LN�} 5.` llST�LU�P <br /> WORK PLAN DATED: 71 <br />' Application Accepted By - Date Issued Area �� 7 <br /> Grout Inspection$y mate Final Inspection By Date <br /> Destruction Inspection By Date <br /> IkE COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# " . FAC# <br /> PE CODES i FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE -4 PERMIT)SERVICE REQUEST# INVOICE <br /> 6 Z� b0C-0 D°r SDS l n SR# <br /> C-57_ WC`WAIVER C-57 Letter of Authorization to sign ermit_Encroachment doc__ <br /> EHD 29.02-00]web <br /> 6121104 <br />