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i <br /> gQUi/y San Joaquin County <br /> Environmental Health Department SITE <br /> P" <br /> �: �•� 304 East Weber Avenue,3rd Floor,Stockton,CA 95202 A'--R1IITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/ehd (I 104 UNIT IV <br /> DR's P Well Permit Application 7T ,pQ�/j <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 5O� Aµ- , 56we.-o <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, an / <br /> Joaquin County De lopment Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> �1�7,WA � I /� 11 ' 1 Assessor •� <br /> WELL LdCBtfon 't P, Cross Street 'Ut tt City Oc0fO Zip 9510? Parcel#[_ IO <br /> PROPERTY <br /> Owner Lircol rrK{-el- Address City Zip Phone# 2� <br /> C-57 Contractor SDedr yn Lf'ctlorc11w1Address 9365 AWlebram 1lDr- city4 Hv^ ZIp95-70S Lic#S1��bX Phone# <br /> Consultant/Sub Cntr LFR, Addressl9Uo POt+cu S}• City m t Lic# Phone# tit 6S�J'�1C00 <br /> 19 " �too� <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ,'KNEW WELL!BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER, THER' n DESTRUCTION (choose type below) <br /> H SOIL BORING# C Q � AL(A/• PRESSURE GROUT <br /> N OVER-BORE. DIAMETER <br /> WELL# TO hP aSSan.�� A <br /> ^' <br /> *Other .� yJO �/1{ld•I1 GROUT SPECIFICATIONS <br /> COMMENTS: L7ol"4' a '��. C Glary ••ll•r• Vo✓es il;+ S PM AAA <br /> TYPE OF WELL INSTALLATION TYPECONSTRUCTION SPECIFICATIONS <br /> n MONITORING ,'HOLLOW STEM DIA,OF BOREHOLE 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: JISTEEL X'PVC BOTHER: <br /> O VAPOR n MUD ROTARY DEPTH OF GROUT SEAL-Iu Fu. TREMIE TYPE TO BE USED: ,KAUGERS 0 HOSE <br /> XAIR SPARGE1 OZONE n PUSH POINT(GP or CPT)GROUT SEAL PUMPED: n Yes O No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> O SOIL BORING OHANDAUGER GROUT SPECIFICATIONS celvlre + %1,e <br /> O OTHER: B OTHER APPROX.BORING DEPTH t'i S '•6 S •Fi• ,BOLTED TRAFFIC BOX or n STOVE PIPE <br /> 1 i'rt�COfl•NDUCTOR CASING PROPOSED No (if YES,list speciricatlons in comment section) <br /> COMMENTS: Wel(S 4o 6e U"s4 Or / SOcrn' A d' Nnrbaiian (, irI0356 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS, <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby ce I that I have prepare this application and that the work will be done in accordance with San Joaquin <br /> County Or 1 ancees, Rules and Re lations,and all applicable California State Laws. <br /> Signed x / 1 Tille/Company l rPn to R iG4 U IF <br /> Print Na cr !n r d'3 Date 27/0 <br /> DEPARTMENT USE ONLY .Z`4 Z p <br /> n ` 7 <br /> SITE MAP IN UNIT IV FILE,AD RE S: rr/fT(!�/�/ T �_( � � ' r� <br /> WORK PLAN DATED: / <br /> Application Accepted By Dale Issued (� d 6 '�1 Area ��� <br /> ae , � <br /> Grout Inspection By D e Final Inspection By te <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECT BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> Z o / z64� /I,a6 SR# D 3 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD 29-02-001 <br /> 6/1/04 <br />