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San Joaquin County <br /> Enviroikental 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 UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 7 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 Developjment Title,,Chapter 9-1115.3 and the Standards toff San Joaquin County Environmental Health Department. <br /> WELL Location— L7 - J -1—r�C;`tt,�y'�fC 1�k S-l` PI PON `J536r Assessors <br /> t r ss Street City Zip o Assessors <br /> Ott <br /> PROPEL 2�9 3 q 8�6Y <br /> Owner AV�p . �, SaN�ers Address ?-o, 3oX 36S City IZi C-J Zip­Z63(ao Phone# <br /> C-57 Contractor 626G6 Dr-1' r�STo�:N� Address 954 Uowr Rd. CityAIReTiNE1 Zip 3V57`3 Uc# &Yd Phone# 97 5--Tia-Sgco <br /> t <br /> Consultant/Sub CnV t>PnM,Fltnz �oNlJllqu+S Address 210I ��/e3i iE2 N, Ix�r City dAKiAaD Lic# Phone# 3/0-663-q2c0 <br /> GIS Coordinates:X �34 831 i1dM ,Y Ll5/&ZOO ,., ,Township Range Section <br /> LAT: 34 yA/ z a7 18W <br /> WORK TO BE PERFORMED: <br /> ANEW WELL 1 BORING CPT,GEOPROBE, YDROPUNC HAND-AUGER,OTHER-) p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# H OVER-BORE. DIAMETER <br /> U WELL# n PRESSURE GROUT <br /> p`Other GROUT SPECIFICATIONS <br /> COMMENTS: CPT bor Ns �0 feet 65s, 2/ ¢0 3 LI FAIt 5106 oW TNJurt rw/ Ave <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> n MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_ 11 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: O STEEL 0 PVC G OTHER: <br /> /0 VAPOR n MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: O AUGERS U HOSE <br /> p AIR SPARGE/OZONE PUSH POINT(GP or(tP ROUT SEAL PUMPED: a Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> )(SOIL BORING o HAND AUGER GROUT SPECIFICATIONS /X•vEr.P/-e A—d NPc,f Cyn,�,.fg�out <br /> IL OTHER: n OTHER APPROX.BORING DEPTH___70 dee!- a BOLTED TRAFFIC BOX or U STOVE PIPE <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 and Regulations, and all applicable California State Laws. <br /> Signed ail0.,. Title/Company Frb h1rLCV/I�(- <br /> Print Name , Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: -)-3O S 4—C16 <br /> WORK PLAN DATED: a3 O S <br /> Application Accepted BBy-r-,, Date Issued I�'� t /O S Area / yZ <br /> Grout Inspection By /'r' • Date d �� a Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> M <br /> ONLY: AID# FAC# <br /> FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> akf <br /> � 4 '�30l7 SR# q5b <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 />