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� <br /> l �) � 'San Joaquin County <br /> 2008 Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 MITIGATION <br /> I- r1K968-3449 Fax: (209)468-3433 Web:www.sjgov.orgrehd UNIT IV <br /> ITf<FfiVlr,E 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 <br /> CO5wn7er �I1 aVdohlJE County Environmental Health Departm <br /> ent. <br /> ip/ <br /> sessors <br /> WELL Location Fairming A Cross Street City �D �1Zarel#i4y <br /> PROPlRTY AddressM*J5 � Clry -�Zpqt�Phone# <br /> Contractor�' odw TN-�rli! j W Address 5509 44 CityRo �.JM zip995uo# 7o-737!'yJ 0 <br /> 7° <br /> Consultant/Sub CntrStfoUs Erlvir0rxjg!jQmss333o6m ,," <br /> P•rkDIA%5C°a�vmP.,KuaYSG'�z Phone# S3rG7(�-AL2 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> W RK TO BE PERFORMED: <br /> EW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> `DdNELL# 1111W - - 0PRESSURE GROUT <br /> O'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> E F WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING OLLOW STEM _rL10 0 MULTIPLE CASINGS p MULTI-LEVEL WELL CASING DIA: <br /> TY DIA OF BOREHOLE <br /> y __ <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS 511.40 AV( TYPE OF CASING: 0 STEEL QVC 0 OTHER: <br /> 0 VAPOR p MUD ROTARY DEPTH OF GROUT SEAL N TREMIE TYPE TO BE USED: O AUGERS 0 HOSE <br /> g AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Xes o (NO E: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> p OTHER: R OTHER APPROX.BORING DEPTH 5 90 POLTED TRAFFIC BOX or 0 STOVE PIPE 3i <br /> CONDUCTOR CASING PROPOSED 2�o (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 Ord7lanc s, les and Regulations,and all applicable California State Laws. � nvi/an.N&n,7L(1 <br /> Signed LN�L.(I [{J7 i ntwCompany &e'04]Ij* 1515 G � <br /> Print Name 5W'VI IDI Date 8-a �-o8 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 9132 4'-- <br /> WORK PLAN DATED: 2.G1dF <br /> Application Accepted By Date Issuedj� O Area,._ <br /> Grout Inspection By Date fa 0� Final Inspection By Date <br /> Destruction InspectIon By Date <br /> COMMENTS l CONDn10NS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 356 v[' ��?� (7/6 9�l Op SR#Opr'g39 <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 />