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LIf6 <br /> SoJoa uin Cou,nty FILE COPY <br /> Environmental Health Department SITE <br /> aha+ 1rr'; i 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> r: <br /> (209) 468-3449 Fax: (209) 411 <br /> 68-3433 Web: www.sjgov.org/ehd UNIT IV <br /> Well Permit Application DEC 3 s :209-i <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> )plication 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 /> ;aquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors t <br /> JELL Location ���1�lOVl[ S1. Cross StreetELl3l�A2�k Cityt�IJ Zip Parcel# <br /> ROPERTY <br /> )weer 1l),Co l-Aec'me-n\C5 Address�•O bZ)x --"'6c) City Zipl-+lob Phone#-111- Sb')-0I00 <br /> -57 Contractor7p--"MkJs&x\lL Address,300 Q\eP,S; S-k . Cit) ti1�Zipcl]-�tLic# ` Phone#S30-66� -Z`/2 <br /> onsultant/Sub Cntr\\L:t-1, % L 6 1-F-)C AddressN!S'Pts,, ` l,-'*' <br /> CAS City c) Lic# Phone#01016)-Z3Z <br /> ;IS Coordinates: N3�� .33�. ,'� 1 1�1•2c�v ,Township Range Section <br /> JORK TO BE PERFORMED: <br /> NEW WELL/ BORING (CPT, GEOPROBE HYDROPUNCH, HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> 1 SOIL BORING# ��' �8'/�5 0 ❑OVER-BORE. DIAMETER <br /> 0 WELL# AP/ 281 fi� 0 PRESSURE GROUT I <br /> 0*Other `/ a) 3 GROUT SPECIFICATIONS <br /> :OMMENTS: — E <br /> I <br /> -YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS I <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 1 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS 0 HOSE <br /> I AIR SPARGE/OZONE I PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 1 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> ]OTHER: 0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE ' <br /> CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br /> :OMMENTS: <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 /> �;ounty O dinance ules and Regulations, and all applicable California State Laws. <br /> Signed - Title/Company Cre ISI �:.�I•f `I�f-{ <br /> Print Nam F - Date L +, L �+ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS' <br /> WORK PLAN DATED: <br /> Application Accepted By Date I Area <br /> Grout Inspection By Date Final Inspec ion b I Date , <br /> 46 <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# F <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR# <br /> C-57 V WC -WAIVER C-57 Letter of Authorization to sign permit Enc ae m-ennjt doc _ <br /> EHD 29-02-001 <br /> 6/22/04 <br />