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• FIDE COPY <br /> a`•'iy., San Joaquin County <br /> Environmental Health Department SITE <br /> " 304 East Weber Avenue,3rd Floor,Stockton,CA 95202 MITIGATION <br /> .P <br /> (209)468-3449 Fax: (209)468-3433 Web,www.sjgov.org/ehd UNIT IV <br /> fz 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^ mpliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department.Assess .r� <br /> WELL Location b WPST u. �e r. Cross Street GeTr t,r City S1 0.� zip Parcel#�� jo7-3 <br /> PROPERTY So�fln S:d-0 <br /> Owner Li-[nw• Cie^ttr Address -City 21p Pho'ne`#'.� <br /> C57Conlractor_'f05tyiftir- COP0. Addres,j)% t /tl6r-ann Dr. City 5 r ip D 70 Lic#7�lDrone0 l;b 906-17 0 <br /> Consultant/Sub Cnlr (.I"12 Address 10 Pot,*A cl- Clly wlrn :li Lic# Phone#NiUo-ySoo <br /> Ir}1h Flea, <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> U NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> ,QWELL# f 3� O aPRESSURE GROUT <br /> a*Other 1 r ' OIM GROUT SPECIFICATIONS <br /> COMMENTS: �or� Yo �w.=t, �Iqr in 4i--t l'lo" oT <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> u MONITORING 8 HOLLOW STEM DIA.OF BOREHOLE'p MULTIPLE CASINGS p MULTI-LEVEL WELL CASING DIA: 2.D <br /> p EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: O STEEL kPVC BOTHER: <br /> p VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 4o 3 0'bd I TREMIE TYPE TO BE USED: gAUGERS XHOSE <br /> AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ),We p (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> U SOIL BORING aHAND AUGER GROUT SPECIFICATIONS pm.o"4 SI�n Pry <br /> BOTHER: OTHERS Eo Onllt APPROX.BORING DEPTH .O t )(BOLtED TRAFFIC BOX or U STOVE PIPE <br /> II� CONDUCTOR CASING PROPOSE/.D No (if YES,list speclocatlons in comment section) <br /> COMMENTS: Wells 'Io { -p Uey A -rdr Air 5(24,4^*- <br /> Atop v,..e ie �r/1oS P5 <br /> 1 V <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby cerflfy that I have pre)al�ad this application and that the work will be done in accordance with San Joaquin <br /> County Or II an ,, Rules and egulations,and all applicable California State Laws. <br /> — / r� <br /> Signedx , /�S T1110Company l 401o9"St 4--! /)li Fk <br /> Print Name \I aSo� f(0'o Date I I0 <br /> DEPORTMENT USE ONLY n <br /> SITE MAP IN UNIT IV FILE,ADDRESS: it <br /> ,0," 7" <br /> WORK <br /> 29-fP0 <br /> WORK PLAN DATED: J.6ti9 <br /> Application Accepted By Date Issued— • Area <br /> Grout Inspection By Date Final Inspection By �•BaIE lb f1 <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PECODES FEEINFO AMOUNTREMITTED CHECK# REC'D 8Y DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR# qs�C <br /> C-5 WC,'WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc 1 <br /> ElID 29-02-001 <br /> 0/12/04 <br />