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y D <br /> aa• �' .. San Joaquin County ME�ST on <br /> 4 o Environmental Health Departmen�'e0Ej\/ED SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 2006 MITIGATION <br /> (209) 468-3449 Fax: (209)468-3433 Web: www.sjgov.ot eWd UNIT IV <br /> `°t'fiaRa� Well Permit Application SANJOP'QU'NCOU - <br /> ENVIRONMER MENT <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE IS400-TH DEPA <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 <br /> /T�ittllle,,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location 42✓`r' /�IYf/��>'G'/ 120A Cross Street lvl 4( ity �`� Zip!3 Parcel#Assessors <br /> PROPE TY p <br /> Owner NVq v/� Address(•0 in N, City fr" ���"� Zip�Phone# ` ✓—d 0 J�� <br /> C-57 Contractor 4(jIttV(; rfeOiAl Address 9 �7_ -2 nj�'� 6".P!� Cit) ',�,��� Zip �1� Lic#U�'lZ7 Phone# F1 4Z) <br /> '✓ 1LZ— Oi Y�c�L� G <br /> Consultant/Sub Cntr/�{(/� V`�U(i �Wly Address df1 Cit Li G? Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> "EW WELL/ BORING (CPT, OPRO , HYDROPUNCH,HAND-AUGER,OTHER') O DESTRUCTION (choose type below) <br /> 0 SOIL BORING#--"— 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> O'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: IvA- <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS N TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE $I�USH POIN O(Gor CPT)GROUT SEAL PUMPED: 0 Yens )l No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS/�✓t`(�'c� � � <br /> OTHER:_0 OTHER APPROX.BORING DEPTH /D r 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br /> COMMENTS: �O�L� A�'�4�✓b-S <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 Or nces and Re ulations, and all applicable California State <br /> Laws. <br /> Signed x Title/Company <br /> Print Name Date 6—2 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRES : ike� <br /> WORK PLAN DATED: (' I <br /> Application Accepted By r Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date <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/1SERVICE REQUEST# INVOICE <br /> SR# VD �� I <br /> C-57_ WC_-WAIVER C-57 Letter of Authorization to sign permit✓ Encr ment doc <br /> EHD 29-02-001 ' <br /> 6/22/04 <br /> 5513 <br /> /Il w <br />