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7�n <br /> San Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 "` `' �(L� : <br /> -r.,1VIITIGATION <br /> (209)468-3449 Fax:(209)468-3433 Web: www.sjgov.og/ehd; <br /> �UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES I 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 ofSa Joaquin County Environmental Health Department. <br /> a � Assessors <br /> WELL Location 1516 5,bl,t(A5t Cross Street LU-1, City 56 Zip_�Parcel# 10-03D_ /1 <br /> PROPER5�j <br /> OwnerMl I 3A(M NO)"fq AddressIJ3� Id, 5LA 4K City 5" Zip'152Z3 Phone# ;Of- qGV-94�3 <br /> C-57Contractor Addresj32 ogn(C CirCif �,jt <br /> ytrd,,,c, Zip757yl Lic#-717510 Phone# <br /> C4 <br /> Ity <br /> C)C W-M Phone# <br /> Consultant/Sub Crit EAVwPork e4lQj Tv-�' Address (414011 4 01,P IC 5 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> Q NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 'DESTRUCTION (choose type below) <br /> 0 SOIL BORING# a OVER-BORE. DIAMETER <br /> )tWELL* a PRESSURE GROUT <br /> a*other GR9UT SPECIFICATIONS <br /> COMMENTS: A15kfl)�'W 0)aM41Mj wtu My- 56ulm? bo'flol-e <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> "AMONITORING 'R�HOLLOW STEM DIA.OF BOREHOLE_L_ a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA:L__ <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS5tkI,UO TYPE OF CASING: 0 STEEL 'WVC 0 OTHER: <br /> UVAPOR a MUD ROTARY DEPTH OF GROUT SEAL 10 TREMIE TYPE TO BE USED: - <br /> JZAUGERS a HOSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yesf 'A'No (TOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS , <br /> 0 OTHER: ft OTHER APPROX.BORING DEPTH %5 `BOLTED TRAFFIC BOX or a STOVE PIPE <br /> t 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 Ordlnan esl Rules and Regulations,and all applicable California/State Laws. <br /> Signed x 4� 0 a'�"T <br /> Title/Company <br /> Print Name :5C':;A <br /> - Date _Z 7­0-7 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE.ADDRESS' i <br /> WORK PLAN DATED: /_ <br /> Application Accepted By_ Date Issued 7 Area <br /> Grout Inspection B _Date_Final Inspection By... <br /> Destruction Inspection By Date <br /> Date--S&.L I <br /> COMMENTS/CONDITIONS: taiLLOL,UjLv) v� <br /> ACCOUNTING ONLY:EAID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D <br /> BY DATE PERMITI SERVICE REQUEST# INVOICEE] <br /> S R# <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 />