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*an Joaquin County <br /> Environmental Health Department SITE <br /> � •1 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd 2005 MAR 2-bNFNI�: 01, <br /> Well Permit Application SAN JOAQUIN COUNTY <br /> NON-REFUNDABLE PERMIT EXPIRES 1YEAR FROM DATEISSUED ENVIRONMENTAL <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applicPub'&' stir yAQ A'%TilAfiJ Van <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location .7 71�r I if&Z:l5L7 2N %'W- Cross Street Vpl1J FJL1p�City _4—jL1CXjr2/f Zip Parcel# <br /> PROPER ��rt77 /�ll` P-6.P�`^-��Ll� <br /> Owner Joe, ,.6++•��� Address 375 (/.1. })fitly IJ Akcity LV4 Zip Phone# 217Y'4�3 ��7�" <br /> C-57 Contractorl.Ot A1MC00 L9J Address 16iL OMC[,C12c--/(1-nG� Cityjwr�;gJ ip yEic# /rsrc Phone# 9 <br /> AH� <br /> Consultant/Sub Cnlr V r.0 I!ilU., Address�i7iT SI-Iltull r�.t• City _Lic# U 7- Phone# %�'�f6'�-JGUAb <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) D DESTRUCTION (choose type below) <br /> 7 SOIL BOR`N1�}# a OVER-BORE. DIAMETER <br /> WELL# IYNi T' IDaPRESSURE GROUT <br /> 'Other TI / GROUT SPECIFICATIONS <br /> COMMENTS: -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> F�ICATIONS a <br /> ' RMONITORING HOLLOW STEM DIA.OF BOREHOLE n i 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING Of Z _ <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS d D_TYPE OF CASING: O STEEL ;APVC BOTHER:- <br /> 1] <br /> OTHER:p VAPOR a MUD ROTARY DEPTH OF GROUT SEALy'1VFCCX I%0/ TREMIE TYPE TO BE USED: p AUGERS a HOSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: U Yes 9 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> E SOIL BORING O HAND AUGER GROUT SPECIFICATIONS YOR-tt Hd'�%n LPi1Nluf <br /> p OTHER:_0 OTHER APPROX.BORING DEPTH 4o I-fBOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> �l CONDUCTOR CASING PROPOSED NO (if YES,list specifications in comment section) <br /> COMMENTS: �PWC15 Dvrl.( Fe 1.6(UtKkMA-5 M©rJ W.ULS b4Si�I-rULb G5s6;P—V4IT01')S <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 Ord i ces, ules and Regns,and all applicable California State Laws. <br /> tatio <br /> Signed x it l` Title/Company A <br /> Print Name G I � ' Date ZL <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED/: G <br /> Application Accepted Byw`-�-Q.�Q Date Issued 3 Z� Area <br /> Grout Inspection By Date 3 Final Inspection By Date 712,9 OS <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 SERVICTREQUEST TINVOICE <br /> 3C �y - 8l ` 9-2 C07 <br /> sR# �c� <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />