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• FILE COPY <br /> UiH San 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 17) UNIT IV <br /> Well Permit Application ��q <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1W <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 Environmental Health Department. <br /> L /� _ �$�10� Assesse 410 3 <br /> WELL Location ODO WP T u. c Cross Street LSG ur Cily �1 Zip Parcel# <br /> PROPERTY/I ( � <br /> Owner h1+rLo�Y1 Cf1kr <br /> , Phone# <br /> C-57 ContractAddressinD-& te54r'ft+ City 0—# zp QS?�Li 0Q <br /> # SLO1l1`o <br /> Consultant l Sub Cntr 1-f Addresslqdo Q04.LI' Sr City mr :II Lic# Phone#(41S)6C3'yS00 <br /> 1¢ti, Floor <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED' <br /> d NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) If DESTRUCTION (choose type below) <br /> E SOIL BORING# • . t l t / Ate' 31, ')f/a g g OVER-BORE. DIAMETER <br /> H WELL# t / �/ 0 PRESSURE GROUT <br /> 'Other GROUT SPECIFICATIONS <br /> COMMENTS: PIA�o '�� -c, Olur�w5 S-'r I'low-S uT .�y pM — 10 A-AIA • — <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING X; [OLLOW STEM DIA.OF BOREHOLE6-9.9S 0 MULTIPLE CASINGS g MULTI-LEVEL WELL CAST G DIA 2-D,r <br /> a EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: g STEEL )KPVC p OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL- 3.0 1 TREMIE TYPE TO BE USED: ,'AUGERS XHOSE <br /> XAIR SPARGE/OZONE u PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ,'Yes g No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 51K01 <br /> p OTHER: OTHER So.: PAIII APPROX.BORING DEPTH O I BOL ED TRAFFIC BOX or p STOVE PIPE <br /> I II !I CONDUCTOR CASING PROPOSED IVO (if YES,list specifications in comment section) <br /> COMMENTS: Wells Yo hie- USSik �Ot' A1r Sna' dK-2✓.^a•c(t )ate D rnoSES <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby ceqyy that 1 have preps d this application and that the work will be done in accordance with San Joaquin <br /> County Or ances,Ru les and 9 guiations,and all applicable California State Laws. <br /> Signedx mac^ TitlelCompanyo'o <br /> Pdnt Name � aS fb • r t o�o Ila 7= <br /> DEPARTMENTUSE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRE S: t _ /-_" f '4L"—"" - " Td'Atf77 <br /> WORK PLAN DATED:_ '2Z 2. <br /> Application Accepted By Dale Issued ,w !eonWIArea �(O <br /> Grout Inspection By Date Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEEINFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> Zqo/ I /W I 5W ' 11,31162 2y SR# VO oto <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc i✓q <br /> EHD 29.02.001 <br /> 6122/04 <br />