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t <br /> t <br /> ,,, San Joaquin County - <br /> o tiM , SITE <br /> Envy eamental Health Department <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> • (209)468-3449 Fax: (209)468-3433 Web:www.s}gov.orglehd UNIT IV <br /> Well Permit Application <br /> II <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin C6unty 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 RepartmentAssessors [� <br /> i-Grave Ls� Rom Cross Stree� City roc Zip qS3 _Parcel# <br /> WELL Location 2335 <br /> PROPERTY s-'f1" a"' ��S ZipWZiO Phone# <br /> d �. . GI�y <br /> Owner -1 �� r�S Address t1 [_�� <br /> of k cJ f Ro CityN�0.r itte Zlp�—t.jc# 516 Phone# 313`58T <br /> C-57Contractor� A�lVril}rya aCy�`�GS,Ad resss i� <br /> Lw LY�J�POhWIPr �� C <br /> �v.c:�.V. <br /> 3-5 <br /> Address Z� 1.. k' City ,� -AWA- Lic# Phone# *D} -`' —1::5: 'Z-- <br /> Consultant!Sub Cntr i <br /> GES Coordinates:X <br /> y Township Range Section <br /> ' �ro IIS►-SI�N4 <br /> WORK TO BE PERFORMED: a 9�` <br /> 5jiEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER, HE *) p DESTRUCTION (choose type below) <br /> n SOIL BORING# It 1]OVER-BORE. DIAMETER <br /> WELL#�li f I G PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: a <br /> a( E <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING OLLOW STEM DIA.OF BOREHOLE o MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: 2 t <br /> []EXTRACTION I]AIR HAMMERIDRIVEN CASING THICKNESS+ `1 d TYPE OF CASING: p STEEL PVC []OTHER: <br /> p VAPOR []MUD ROTARY DEPTH OF GROUT SEAL_ TREMIE TYPE TO BE USED: UGERS WHOSE <br /> 0AIR SPARGE!_QZONE ]]PUSH,P_OINT(GP__or GPT)GROUT SEAL-P-LIMPED:.- --Yes -p-No-(:NOT:MAXIMUM=FREE�FALL DEPTH-IS 30)--;;­#� <br /> j]SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS /arena/.. t�yuPJ1/L"� <br /> p OTHER: OTHER '1 APPROX.BORING DEPTH ZS' []BOLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED V1 (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48.WORKINGHOURS NOTICE REQUIRED FOR,INSPECTIONS.. <br /> hereby certify that I have grepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi s I andAeons, and all applicable California State Laws. ��fSigned x TitlelCompany�i1o+.r/�/an � ir /''Print Name ! Date J/rzaj <br /> DEPARTMENT USE ONLY. <br /> SITE MAP IN UNITIV FILE,ADDRESS: . <br /> WORK PLAN DATED: <br /> Application Accepted By ' r Date Issued <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS!CONDITIONS: i 1 <br /> :i <br /> ACCOUNTING ONLY:, AID# j FAG# <br /> P>=CODES FEE INFO AMOUNT REMITTED CHECK# REC'D Y DATE PERMIT!SERVICE REQUEST# INVOICE <br /> Q �i� 1 SR# L'< <br /> C-57-- WC -WATVER_'r C-57 Letter of Aut6ri i gn permit Encroachment doq +' <br /> EHD 29-02-001 <br /> 6/22/04 <br />