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- M <br /> •cc, j <br /> �` an Joaquin County <br /> Environmental Health Department SITE <br /> 304 East� Weber Avenue 3rd Floor Stockton CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/ehd <br /> UNIT IV <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 /> .. WELL Location 4 191 �f C�1 ("Q ry n �p� 5 .0 Assessors <br /> �j�+.L Cross Street P e S Frere k ^�ip SZ3 Parcel# !q_3_ <br /> -- y Q -1 <br /> PROPER <br /> / C i T , r �,�/ �7^� <br /> Address I �jo City I�Zip 5ZZ4one# q I S- 1 J r 12-944 <br /> C57 Contractor_ , �•(7C,o (/y3Cc C Gio'�/,, �,�, <br /> �7 City Zip Lic# Phone# <br /> Consultant/Sub CntrSCO 2 Address_3 Q ✓11 � ° K ity Pd1�c a'Mi / Phone# <br /> .,., GIS Coordinates:X Y Township_ 1 15 Range Section K 3Ol <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> wr 0 SOIL BORING# <br /> a LL# Q OVERBORE. DIAMETER <br /> Other A err;I( / 0 PRESSURE GROUT <br /> J GROUT SPECIFICATIONS <br /> COMMENTS: -00/gni e- e A S t I DC�iD�l <br /> TYPE OF WELL�jl'1 INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA_OF BOREHOLE j�! 0 MULTIPLE CASINGS <br /> Q MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC 0 OTHER: <br /> 0 VAPOR 1]MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS [I HOSE <br /> fITR SPAR OZONE GP or CPT)GROUTSEALPUMPED: QYes 0No NOT : MAXIMUM FREE-FALLD TH IS 30') <br /> GROUT SPECIFICATIONS... HER: �GI�' APPROX.BORING DEPTH Q BOLTED TRAFFIC BOX or p Sf6VE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications In comment section) <br /> COMMENTS 14cl nj Iluaceed 6a f172CU S -+d IF k-jQ S <br /> r <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 tqls application and that the work will be done in accordance with San Joaquin <br /> County Ordi aces les and Reg tions,and all applicable California Statue Laws. Q' <br /> Signedx Cotle/Company-)OA, P . <br /> Print Name t AR 14-n e- '- 1�< Date <br /> DEPARTMENT USE ONLY /Y <br /> SITE MAP IN UNIT IV FILE,ADDRESS: "A E• �'" z�-so <br /> WORK PLAN DATED: <br /> r.r ,Application Accepted By Date Issued l 2 �� s Area d <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> r PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 21 o ( 4581� &q"-, / /3 SR# Q SLY_/ <br /> C-57 &WC - AIpVE�R C-57 Letter of Authorization to sign permit Encroachment doc_ <br /> EHD 22104 -001 ► G�1 —+ `/:J�� �j) �G. <br /> 6/22/04 � �/ � <br /> t.�o c-5I • <br />