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oP,qU!^r. San Joaquin County <br /> Envie -amental Health Department SITE <br /> N: { 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 /> � �P <br /> ORt� 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 of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location I d'. (� 2 = Cross Street t L City �j-Caat+^ Zip'1SZfl S Parcel# <br /> PROPERTY <br /> Ownne�l or 4 +-F S �c �-/nw. Address ZZ�t t^� ``�'���': _City 4-- Zip`I;2113 Phone# Z- 9y6 -'07-44 <br /> C-57 Contractor� Address'Z�L� y):t%A— ➢r City Zip'TCOCLi IZZ64Phone# <br /> Consultant/Sub Cntre. Address 14 oV City Cc-..a t. Lic#?4 t'16A Phone#&7 r) <br /> ..: 'S to <br /> GIS Coordinates:X Y t &I. 3+0 7-t 7Z ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> "NEW WELL/ BORING (CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> XWELL# 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> i <br /> COMMENTS: fS- A , I O - Z ✓- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ,If-MONITORING 10HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _ <br /> 0 EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS Z " TYPE OF CASING: 0 STEEL x PVC BOTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS AHOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Y s 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS :.4 Ce.N.-s. ► I <br /> 0 OTHER:_0 OTHER APPROX. BORING DEPTH 1 D t S' OOLTED 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.Ordinances, Rules egulations, and all applicable California State Laws. <br /> Signed x Title/Company n� •c : T �S <br /> Print Name .. �� � Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 15 �� <br /> WORK PLAN DATED`:/y (� r <br /> Application Accepted By Date Issued `t 7 Area4 -- <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: CSV F G✓0 ( 17 ad `-' i <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> G 70—/ <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 />