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�o "' o fan Joaquin County ED <br /> i Environmental Health Department �'J ` �=� LJ SITE <br /> " 304 East Weber Avenue, 3rd Floor, Stockton, CA 9�U 7 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.s_691, '!�{ /ehd UNIT IV <br /> ' ORN Well Permit Application p;c;7;� �i , �;, ;,;a;!ry <br /> P <br /> I L-j <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 /> WELL Location L13 S I)�a�- V-\00 '0, X tJ, Assessors p� <br /> �_„ Cross Street City �Zip�s�aParcel#�IL=�QQ <br /> PROPERTY ` ` \\ /�2 ` I 1 <br /> Owner VJ -"Add ress_��,5 u}cxlet^Ic90 City �K'� Zip��phone# [[ZP5-) Q 3 I " y <br /> C-57 Contractor Y'f 4 Address tYF�t�(�-p( �tQCx City 4l {lip9 qW--Lic# C65Wl5Zne#�9 .3 <br /> Consul t/Sub Cntr rn -n- � Address, \Q0 1101115 SV City p U Lic# q-�Z Phone#��� <br /> GIS Coordinates:X 'y Township_____.:_Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING JCPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') Q DESTRUCTION (choose type below) <br /> 3( OIL BORING# t" Q OVER-BORE. DIAMETER <br /> ELL# Q PRESSURE GROUT <br /> Q*Other t� GROUT SPECIFICATIONS <br /> COMMENTS: 5;3A ',L rsjn, Zy/ "1 2 Cx1-icc © p�� aOz I f Ups �9�0-�S?h�aS �• <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS / <br /> pAONITORING --A10LLOW STEM DIA.OF BOREHOLE Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION Q`AIR HAMMER/DRIVEN CASING THICKNESS 05 TYPE OF CASING: Q STEEL PVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT S / TREMIE TYPE TO BE U ED: �UGERS Q HOSE <br /> Q AIR SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: es No (NOTE: MA IMUM FREE- ALL DEPTH IS 30') <br /> 'SOIL BORING Q HAND AUGER GROUT SPECIFICATIONSkwa <br /> Q OTHER: Q OTHER APPROX.BORING DEPTH — O 4 OLTED TRAFFIC.&X or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED(if YES,list specifications in comment section) <br /> COMMENTS: TTT� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County O di ances, RulesM�n <br /> s, and all applicable California State Laws. <br /> Signed x f^� Title/Company eN,U(' �e t- kM <br /> Print Name E-{ • Cti l� Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By 1 Date Issued'919Area <br /> Grout Inspection By Date GSC 4WW final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: Or <br /> ACCOUNTING ONLY: AID# C� S <br /> FA <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK/# REC'D B DATE PERMIT/SERVICE4REQUEST# INVOICE <br /> 0 Co 10 Z a b S R# <br /> C-57_ WC=WAIVER_ C-57 Letter of Auth z io o sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />