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AQ�tN San Joaquin County <br /> Environmental Health Department SITE <br /> IN= k `'< 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 MITIGATION <br /> t i <br /> •f (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> \:;=�QYR% 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 !✓y� l��/�l��y f Cross Street City I'LFun�/e� Zip L 1 r Parcel# <br /> PROPERT > �/ y �l f Zip j{.!Phone# <br /> Owner&#�]� L' Address 7ZSZ� / / / C+ty <br /> C-57 Contractor f�/J�' L�) Address ?�5 7ILK�.' I ,/l City JTK-L^--Zip Lic#�G'7112,2hone# / <br /> Consultant/Sub Cntr/fl��4t'&-Ld tr 'c') Address_'3 4�7, "/City " <br /> � Lic# 7i Phone# �7 7 L1 � <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> VEW WELL/BORING O T,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') Q DESTRUCTION (choose type below) <br /> VSOIL BORING# DOVER-BORE. DIAMETER <br /> Q PRESSURE GROUT <br /> WELL <br /> Q WELL GROUT SPECIFICATIONS <br /> *OtheCOMMENTS: -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING Q HOLLOW STEM DIA.OF BOREHOLE_,2_L MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION Q AIR HANIMER/DRIVEN CASING.TH ICKN ESS &09- TYPE OF CASING: Q STEEL Q PVC Q OTHER: _ �_ <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL Z.j�/ TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> Q AIR SPARGE/OZONE ITA <br /> PUSH POINT(GP or CPT) SEAL PUMPED: Q Yes g'No (NO : MAXIMUM FREE-FALL DEPTH IS 30') <br /> 1r➢SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS t'�MlZh1�'A (CrML"rr <br /> JQ OTHER: n OTHER APPROX.BORING DEPTH �L�� Q BOLTED TRAFFIC BOX or Q STOVE PTFE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: !L BLT%w7is L/!✓Lj <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 43 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 OrdAances Rules and Regulations,and all applicable California StateLaws. <br /> Signed x r J Title/Company l//` <br /> Print Name Date / r "��—1 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: S <br /> WORK PLAN DATED:-yy� L <br /> Application Accepted By /�t r Date Issued f/ 1. Q Area y 2-- <br /> Grout <br /> Grout Inspection By_��M��tM Date 1 � U`t Final Inspection By LtULt rct, Date 1 t g �` <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> TACCOUNTING ONLY: AID# FAC# <br /> FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATET;; <br /> VICE REQUEST# INVOICE <br /> A% � # 9b 33 c7 <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 />