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u I;v �II JQiPigi&FrFIOn <br /> "'0 ) <br /> o� <br /> l—,". <br /> E yEj'vironmental Health )Department SITE <br /> � !i`" <br /> I i' `` r} `" -- 600 E. Main Street. Stockton, CA 9202-3029 MITIGATION <br /> ( 0V 468-3449 Fax: (209) 468-3433 Web: A-ww.sjgov.oj-g/ehd I <br /> \ .cs r, r•� b �lJ } UNIT V <br /> Well Permit Application <br /> �A((r'`eEFU:lDABLE PES <br /> y.,hx IMT EXPIRES A VCAC CFORA r,ATE ICCf IEr1 <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 Environmertai Heafth Department. <br /> Assessors <br /> WELL Location Cross Street City=kc"• ii)r's Zip q`po Parcel# 1,=:9--U r3-''< <br /> PROPERTY <br /> Owner LkaLr <br /> Address j�; c, i'll4�?C1 Phone# C7$s_-}u5fi <br /> C-57 Contractor(`;nm 'f u;lirn E &nrl'Evs ns Address rim i}c;_r:` P_ rl City HavlZne ZipCi' 3 Lic# !r " Phone# " 16 QhJ <br /> 3 <br /> Consultant lSub Cntrfkij;'tn-srr( Address K^i �;,g;(a 42e,<r7 Phone# <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> "NEW WELL 1 BORING (CPT,GEOP ROBE, HYDROPU NCH,HAND-AUGER,OTHER*) u DESTRUCT!ON (choose type below) <br /> -SOIL BORING# 0p-r•-1 u OVER-BORE. DIAMETER <br /> SWELL# Kik,-( , t-U>-O, HIL-3 0 PRESSURE GROUT <br /> u*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 'HOLLOW STEM DEA.OF BOREHOLE), 2" u MULTIPLE CASINGS ©MULTI LEVEL WELL CASING DIA: <br /> u EXTRACTION u AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: u STEEL u PVC u OTHER: <br /> u VAPOR u MUD ROTARY DEPTH OF GROUT SEAL V(An�i i,(Y TREMIE TYPE TO BE USED: u AUGERS u HOSE <br /> u AIR SPARGE/OZONE likPUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes u No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> A SOIL BORWG u HAND AUGER GROUT SPECIFICATIONS <br /> Q OTHER: u OTHER APPROX. BORING DEPTH " U'cjncl 00 ,gBOLTED TRAFFIC SOX or u STOVE PIPE <br /> CONDUCTOR CASING PROPOSED to (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 /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi nces, Rules nd Regul ions, and all applicable California State Laws. I� <br /> Signed x- //,/ Title/Company ViC'F t��PC1C�C�f4. 1 V[1(l�(Ci �1P�tt}3)',rr7;nYY�(�1i�ui .141r - <br /> Print Name K r Date nt U0 Ug <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: I�-30 W <br /> WORK PLAN DATED: 'L <br /> Application Accepted ByAy Date Issued t vc- o� Area �6 1 <br /> Grout Inspection By r Date 'I<1 l�� Final Inspection By - Date O <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PIE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT f SERVICE REQUEST# INVOICE <br /> ��n3 ou zi"s3 �J -1 $v4 . o� SR#f0a531bG} <br /> C-57—ZWC-," -WAIVER_„_ C-57 Letter of Authorization to sign permit_^__Encroachment docT <br /> EHD 29-02-001web <br /> 6122/04 <br />