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elan Joaquin County • <br /> Environmental Health Department SITE <br /> 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 /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES t 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 <br /> Environmental Health Department.Assessors ssessors <br /> Cross Street .fo KrZ <br /> WELL Location Rsto Parce — <br /> ^ I 3_ 06a-3S <br /> PPR0Pi�CSlifp�'Sialto /0 I[5 �Addresjoo Wwu' /�((�tqA/nC , Ciry "�X Zip 18x16 Pher.e# 2s3-Byl-saol <br /> CS7 <br /> Contractor) OoJw W,llli'"r1(v Addmss (-)(JDI`u1 hAj City /r, Pi5k Zip ±q57Jic# 710O� Phone#j07-37V-V300 <br /> ConsuNant/Sub CnV��'ra�i/S E✓Ivifonrna+r�i A,d'dreaa 3330 G�1a�1 PwK Di.'�y CaAI"k Uad5"-' Phan# S <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED' <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) D STRUCTION (choose�pe below) <br /> 0 SOIL BORING# VER-BORE. DIAMETERS /10" <br /> ESSURE GROUT <br /> aWELLWELLr# R 7 o/GROUTSPECI/FI,CATIONS <br /> COMMENTS: ((r-1ASh�1d f(?1U WSJr✓1 bOrGt611'� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> -10NITORING HOLLOW STEM DIA.OF BOREHOLE_ U MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA: <br /> u EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: B STEEL U PVC B OTHER: <br /> u VAPOR u MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS u HOSE <br /> 0 AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING S HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER: n OTHER APPROX.BORING DEPTH O BOLTED TRAFFIC BOX or a 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. o <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordipancesutas and Regulations, and all applicable California State Laws. <br /> StM4.t pp CJ <br /> Signedx C ��.{ (D / Title/Company 64 I JIYp S 6F nv'fian / � <br /> Print Name lA 17i T11 Date 0 -- 1—o8 <br /> DEPARTMENT USE ONLY elk <br /> .{ <br /> SITE MAP IN UNIT IV FI ,ADDRESS: 4- . 26 elk � L'o P <br /> WORK PLAN DATED: a, V `! <br /> Application Accepted By Date Issued -/ t () Area 9 _ <br /> Grout Inspection By Dale q Final Inspection By Date <br /> Destruction Inspection By Date / q <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK t RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3Sb2 bow 6a� /�oPo 1.I Z.- A 'e o. sR0067 fa <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 622/06 <br />