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COPY <br /> °'" �� San Joaquin County <br /> Q a Environmental Health Departm SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 9 <br /> aa� MITIGATION <br /> " ( b8-3449 Fax: (209)468-3433 Web: www.sjgov.o <br /> oRa� �p1MENR\C�r' UNIT IV <br /> 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 Title,Chapter 9-1115.3 and the Standards ooffwwSan <br /> ""Joaquin County Environmental Health Department. <br /> � ds city I-#700e p j7Sj Assessor 51 <br /> WELL Location �u. Cross Street TCi Zi Parcel#_ 2q 1. M- <br /> PROPERT`� 4;1-16) <br /> � y � � R� � �� <br /> Owner ddr �`�&'01 C._,.- .,dy( uoZe".Zip 544 hone# 11d-15r!v <br /> C-57 Contractor St Ec jolA p Address u 3(PS�wr5r.a4 r✓ City k'✓ Zip Lic#S/aa6 Phone# jL4 5 <br /> Consultant/Sub Cntr KkIU'I"LVey- Address City RL t✓ Lic# S�Phone# <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> g NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> SOIL BORING DOVER-BORE. DIAMETER <br /> WELL# " H 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS c,.r <br /> ' COMMENTS: I�1'l�OfcII�U4tfDt�be � G*b5 G6 pc'-4 Z41-OZO-51 �) (�bt-aC.¢1 (I,r.� r✓e-t-� 2(X)� 56 <br /> T� � Ro4ot <br /> MW <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ' `MONITORING WOLLOW STEM DIA.OF BOREHOLE S ry 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL- S/ TREMIE TYPE TO BE USED: )(AUGERS 0 HOSE <br /> ' a AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes xNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Nea4 ee&4z+ <br /> 0 OTHER:_0 OTHER APPROX,BORING DEPTH 31- XBOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> tCONDUCTOR CASING PROPOSED /Ily (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 Ordi/n_a nf�jes, Rules andel Re ulations, and all applicable California State Laws. J/ // /J <br /> Signed / (.S�/�iQ Title/Company 5ybgd& �j1 /e1w,41G(er- <br /> ' Print Name rjwwts /� /VP-40V Dale <br /> DEPARTMENT. R,•T,M€NT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> ' WORK PLAN DATED: 1 <br /> Application Accepted By Date Issued 1 1 7 A Area <br /> ' Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ' ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR# D <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign perni Encroachment doc_ <br /> EHD 29-02-001 Llr. ._n <br /> ' 6/22/04HD2 �4`^-"amu' <br />