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o¢° i" *San Joaquin County • <br /> Environmental Health Department SITE <br /> 600 E.Main Street,Stockton,CA 95202-3029 I GATION <br /> { (209)468-3449 Fax:(209)468-3433 Web: www.sjgov.org/ehd 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 /> l!Q 1 r ty F CA�zs 9523( Assessors <br /> WELL LocaUo,2f//r /eWb 44 rd*,.V cross Street lt�� 9 ci p Parcel# L01103004 <br /> PROPE,RV p <br /> Owner,-ItIl O&S CAnrP I?l/ Add,,,,? // P,C15L1ett CA�t'�dy ,p_&24 Phone#Zo 9- <br /> C-57Contractor/A100/)/t/AID PA/CC/�Addmss fD 60X 336 City,& 4111 ip?5/fXic#7lao hone#7of37f�yi�0a <br /> Consultant/Sub CntrNOL YE f 4XSOC. AddredY S tet/ 9 S qty St4G Lilt r7 t- Phone#�/�G�IO zl --Wlru <br /> GIS Coordinates:X ,Y Township '7g�f(�^''7gg Range / G Section O <br /> WORK TO BE PERFORMED: ' <br /> XNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) p DESTRUCTION (choose type below) <br /> D SOIL BORING# 0 OVER-BORE. DIAMETER <br /> kWELL# IM —m W a PRESSURE GROUT <br /> (]-`Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING ,HOLLOW STEM DIA.OF BOREHOLE u MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: 2 <br /> a EXTRACTION u AIR HAMMER/DRIVEN CASING THICKNESS SG N YO TYPE OF CASING: U STEEL $"PVC G OTHER: <br /> 0 VAPOR p MUD ROTARY DEPTH OF GROUT SEAL 30 a TREMIE TYPE TO BE USED: °AUGERS hx-IOSE <br /> AIR SPARGE1 OZONE aPUSH POINT(GP or CPT)GROUT SEAL PUMPED: })-Yes allo (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> Q SOIL BORING a HAND AUGER GROUT SPECIFICATIONS 8f�T�CEArENT <br /> OTHER: B OTHER APPROX.BORING DEPTH S"O` Q BOLTED TRAFFIC BOX or, STOVEPIPE <br /> CONDUCTOR CASING PROPOSED (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 /> 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 an_dRe�gulati%on;;,and all alicable California State Laws. T <br /> Signed x �lsiy2cTr '.C _Title/Company �.Q���tGi�/ �1�0�/✓.R�� (�,Q/CC/•a.G <br /> Print Name. <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 3O t 9 <br /> WORK PLAN DATED: -5 ZZAob / C <br /> Application Accepted By. Date Issued 5I_I d Jam-" AreaI�bI Z)/ <br /> Grout Inspection By lA�n.�acc•+.- Date s 3r Io' Final Inspection By b(�t,vt�y� Date 6 W O fi <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: All FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'DtBY jDATIE PERMIT I SERVICE REQUEST# INVOIa` 07. � eq•°oi I0?-q I ( ( a/o7 SR# 5063(0 <br /> C-57 -/ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001web <br /> 6/22/04 <br />