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'C.— <br /> oPq San Joaquin County ; a fttl&- <br /> Environmental Health Department OAQUIN COUrI-N SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 9ftVIFtO1,IMEt MITIGATION <br /> •= :" (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.orpWi'1 DEPARTMENT UNIT IV <br /> ;'9F b" 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 /> } e � I �' I 9520 6 Assessors 9l p <br /> WELL Location 2,Q' � ��� ��. Cross Street City Zip Parcel# ,' `� 30 <br /> PROPERTY Cf/lc�Or1�­4-'a/a er� <br /> Owner +� Address City Zip Phone# <br /> = / /� fW'-Sq- � c t"^rs t�s s Z7 <br /> C-57 Contractor Ta�t?r (.r9/151�1rn1:Address 3a✓! .tip 1'a! �l� CityZip fS(�t f Lic#�� hone# la "3'(—f b�� <br /> f <br /> Consultant/Sub Cntr SQ �' Address City Lic# Phone# <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOP ROBE,HYDROPUNCH,HAND-AUGER,OTHER") 0 DESTRUCTION (choose type below) <br /> SOIL BORING# 0 OVER-BORE. DIAMETER <br /> XWELL# a PRESSURE GROUT <br /> �0*Other _T GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> �{ fv1ONITORINGiOLLOW STEM DIA.OF BOREHOLE QD+I a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: 11 <br /> 0\EXTRACTION /a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEE2�c: <br /> PVC 0 OTHER: <br /> 0 VAPOR AMUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ,Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATION A of e-j- <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 /> w � <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 x �'' .t- Title/Company 11s/�l�'/�� uyr;k P071111 — <br /> reA /Al <br /> . <br /> -__( <br /> Print Name /��T/l�{ S +✓�-� - Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: i v o F11 r P U V <br /> WORK PLAN DATED: { v is o <br /> a Boman WWI Ir <br /> Application Accepted BDate Issued =( i"-j 01 Area <br /> Grout Inspection By Date Final Inspection By Date �O <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <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 />