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W <br /> Op0.uAN can Joaquin County <br /> Environmental Health Department SITE <br /> N 4V .. <br /> { 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov. org/chd <br /> TIT&) y <br /> �q. :.Ii f Y <br /> 4Poa� 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 Ti%r� _tpter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> I (� tl) 0 Y P c Assessors <br /> WELL Location ' ass Street � 6 Zi l 5c:�< arcel# <br /> I tet- r <br /> PROPERTY A. g , GUI ,J C , t I P ` �- ' <br /> Owner �(t� CtF ����1�- �a Address � L/ �� I" � �CA City V�� `�"� Zip ( � Phone# �A � l tl <br /> C-57 Contractor r ,�U� �Y`Y�(1Cdd�esiy�� c(iCAty V�-u .,ZipaLlc SI `''I Phone# �� <br /> _ /� <br /> pp !<. y �� . E�tiJrl�-F'�( 0)' LJ eJG Lick � VK(� Phone# �f- f� ��� I ✓� V .� <br /> Consultant / Sub Cntr 1. l 1/00,114 ff 10f.h:�•'Addfess y <br /> /Vf s co <br /> GIS Coordinates: X., Y., Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL / BORING (Cp GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") p DESTRUCTION (choose type below) <br /> y�] SOIL BORING # o - �?�'-`� D OVER-BORE. DIAMETER <br /> O WELL # _ . 0 PRESSURE GROUT <br /> O 'Other. GROUT SPECIFICATIONS <br /> COMMENTS : II i'lt�( /' d\��+-�'t <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE_ ]] MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ]] STEEL 0 PVC 0 OTHER: <br /> a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: [[ AUGERS 0 HOSE <br /> 0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT) GROUT SEAL PUMPED: 0 Yes ONO (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: 0 OTHER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 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 Ordina Ge7� lee nd Regulations , and all applicable California State Laws, <br /> Signed x n, L ((// ..�// Title/Compa/ny l✓ lX Qt J� CXX r-1 r y ( � 6 <br /> Print Name 'J/rw e ' `� ( �[ )! }� /t yL L-7 , 1r) 4 Date t <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : 1 3 0 N oY4k b u n -i- e r S + r e e f <br /> WORK PLAN DATED : Ja 7111 t3 r 2i 9 0 05 <br /> Application Accepted <br /> 1By V t C 4-n r 1 Q L . 1Y \ LI r"f n e v Dale Issued 1131 05 Area 14 5 9 <br /> Grout Inspection By Y iC�"M� G�mEf� _ _Date Z U Inspection By ate Z 0� <br /> Destruction Inspection By Date <br /> COMMENTS / CONDITIONS: C Emen + epf sai I loorinqs - <br /> qffi <br /> ACCOUNTING ONLY: AID# - FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> 3501 g ?' 00 g `� • D0 S 004 / 0 ( & <br /> C-57_ WC.-WAIVER. C-57 Letter of Authorization to sign permit_ Encroachment doc <br /> ERD 29-02-001 <br /> 6/22104 <br />