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• ORIGINAL <br /> San Joaquin County <br /> r 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 , „r)IP UNIT IV <br /> P0B Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED /A/ J <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 /> Assessors <br /> WELL Location�98SS u/. G�..t.fi Kne RdCress Street HoySt7��t PKwYCiry T• _zip 9539/ Parcel# gt 6(o0-A3PROP1 <br /> OwnerER U2�a ISS, Address 7 ILQN loWCf 1/Y•Ck IV rNOC Zip_? <br /> a F y� et t / SO phone# <br /> C-57 ContradorYfW Dili �tA�1//(G /Address PO-BOX ���i Cityj�Sl �e,,n"�.,zip 611/Lic#72090VPhone<±/6)777-WOO, <br /> Consultant/Sub CntrM?((dee�l�t/RIIASS04 ddress97ro w-ff"40 .A ityS�A4Lic# PhonWZ041)2_3y-7722. <br /> GIS Coordinates:X TFA ,Y ,Township T J Range yE Section 40 <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION (choose type below) <br /> a SOIL BORING# u OVER-BORE. DIAMETER <br /> �M/ELL#:t VJ D 2. D -0$ aPRESSURE GROUT <br /> '0'*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ,MONITORING XHOLLOW STEM DIA.OF BOREHOLE,, o MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: Zp <br /> a EXTRACTION g AIR HAMMERIDRIVEN CASING THICKNESSSCh Yo TYPE OF CASING: u STEEL rVC a OTHER: <br /> g VAPOR g MUD ROTARY DEPTH OF GROUT SEAL —(07 TREMIE TYPE TO BE USED: )gAUGERS 0 HOSE <br /> g AIR SPARGE/OZONE g PUSH POINT(GP or CPT)GROUT SEAL PUMPED:Wes ONO (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> a SOIL BORING aHAND AUGER GROUT SPECIFICATIONS neat cement <br /> g OTHER:_O OTHER APPROX.BORING DEPTH .257' g BOLTED TRAFFIC BOX or)OTOVE PIPE <br /> CONDUCTOR CASING PROPOSED ^1b (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, <br /> /Rules <br /> �and Regulations,and all applicable California State Laws. <br /> Signed x �—<_e Lf t'Vt=�v+-. Title/Companyf/'o� oto/rr /s� �G��al/t�eG-ku hl f�s'SQG - <br /> r <br /> Print Name Fred W. CGius Date AtAgtAS'r <br /> u <br /> DEPARTMENT USE <br /> ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: lO `7-pb c�GCE-ILS G�-�( • / e-� 2- 6$� <br /> WORK PLAN DATED: 4f-uv-Or <br /> Application Accepted By Date Issued 5 Area <br /> Grout Inspection By Date Final Inspection By e / 5 <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> '-o MAI sR# p0T2 <br /> C-572 WC :�-WAIVER_ C-57 Letter of Authorization to sign permit-2L Ensr-eAc ment doc_ < <br /> EHD 29-02-001h <br /> 6/22/04 <br />