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q .t .Py6 * 0 FILE COPY <br /> ,o. 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.sigov.org/ehd UNIT IV <br /> Well Permit Application 5n�- <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED T V-- <br /> Application is hereby made to San Joaquin County for a permit to conslruct 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 Environmental Health Department. <br /> WELL Location 999 We rn I�el�' 1/f, Cross Street tR bMc 1�1 _ p islD-, .Assessor 7 (10 <br /> '` Cily �T o n Zi Parcel# / <br /> oath S; a. <br /> PROPERTY/I�[o'r1 n <br /> Owner L 11 ( s+lttr' 1Address ,n City Zip _ Phone# <br /> C-67 Contractor�i7e�Tftivvl LXA6'4T'.Akidrass t6S (U`n04Hn Or. Citys 4L Z <br /> �- //�1 p _ �'or}:}nN Zip9S�pS.LIGt Phone# 4I,S-4�l?. <br /> Consultant/Sub Cnlr LEP- Addross�Yd0 r'04.r,11 SI' City .arn Jlf,Lic# Phone#LM1S k2-9S#o <br /> GIS Coordinates:X ,Y ,t'P.lfi Floor Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNGH,HAND-AUGER,OTHER') a DESTRUCTION (choose type below) <br /> II SOIL BORING# �Y <br /> ,a WELL �,//rM//. [I OVER-BORE. DIAMETER <br /> O'Other 0 PRESSURE GROUT <br /> I' r GROUT SPECIFICATIONS <br /> COMMENTS: (�.)o��- -a la ..-c- oIG i Tarr �owrS oT (zQM 10 AAA <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING POLLOW STEM DIA.OF BOREHOLE H MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 7.D <br /> 0 EXTRACTION E AIR HAMMERIDRIVEN CASING THICKNESS TYP11E OF CASING: 0 STEEL 'kPVC E OTHER: <br /> Q VAPOR ()MUD ROTARY DEPTH OF GROUT SFALtg TREMIE TYPE TO BE USED: 'AUGERS HOSE <br /> ORSPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ) ,'Y^es 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING OHAND AUGER GROUT SPECIFICATIONS I SINf�'V <br /> 0 OTHER: n OTHER APPROX.BORING DEPTH .O I )(BOL ED TRAFFIC BOX or 0 STOVE PIPE <br /> {els CONDUCITOR CASING PROPOSED �Vo (if YES,list specifications in comment section) <br /> COMMENTS: W o USW -Fpr H1/' Sr7 ArMt, d we,o{1 )o nv,rn ores <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby ce fy that I have prep& d this application and that the work will be done in accordance with San Joaquin <br /> County Or I ances, Rules and gulations,and all applicable California State Laws. <br /> Signed x Title/Company ( 1!Q loM'S� t.-/ ri Fk <br /> Print Name <br /> Date/Q <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: A-G 1t <br /> WORK PLAN DATED: O(p <br /> Application Accepted By _ Dale Issued rea LIA <br /> Grout Inspection By Dale Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> kACCOUNTING ONLY: AID# FAC# <br /> DES FEEINFO AMOUNTREMITTED CHECK# RECD BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> Ind � / s3 / y o sR# pd 3 I <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc N <br /> EHD 29-02-001 <br /> 6n2/04 <br />