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San Joaquin County COPY <br /> Environmental Health Department SITE <br /> N :'< 304 East Weber Avenue,3rd Floor,Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> �P <br /> L Fo Well Permit Application J( //jam Ra W <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED V � `�— <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 DepartmentAssessors w <br /> Row <br /> r iI _ p�Parcel# <br /> WELL Locati��90 c 1�iD i h Cross Street a nr City S�oe. on Zi <br /> Lt <br /> PROPER „ t1 tjl L ddre /�16 �, 4��Y�Zip 7 b�Phone# <br /> Owner </ �LJC pp Ad\tlresS v r,!t ��n���`���.� <br /> C•57 Contractor `IifppOppVl 2.X �(f;,-. Address 110 hA6lM< �Lf•City LEanrlfO ZipT 9 LicpaeS Phone# <br /> consultant/Sub CGtr�"U 1 L Address I'/�0 fOWt.�� S� Cit Wl JiII2.Lic# Fhane# SIS -BII <br /> I�� Frh•� <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> Q NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION (choose type below) <br /> a SOIL BORING# M.S19-12 7 MT/�''1 J 0 OVER-BORE. DIAMETER <br /> n WELL# n PRESSURE GROUT <br /> fl'Other P 1 1- GROUT SPECIFICA`TIONrS <br /> COMMENTS: I11 r a- C PT 1 E � �±C,„L .0'OA(fC W rIQ [lP 1w,.nlyeWM.r `MG.4 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> F MONITORING E HOLLOW STEM DIA.OF BOREHOLE�1_O� 0 MULTIPLE CASINGS n MULTI-LEVEL WELL CASING DIA: <br /> n EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL p PVC 0 OTHER: <br /> E VAPOR a MUD ROTARY DEPTH OF GROUT (o SN <br /> SEAL f ac,2 TREMIE TYPE TO BE USED: 0 AUGERS XHOSE <br /> n AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes ONO (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> E OTHER: n OTHER APPROK BORING DEPTH 2Q. 6' n BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> �A D CONDUCT R CAIgING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: MTf i- Cr� QY� I�f n Lt�Nl�IfA4 C - <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 th” application and that the work will be done in accordance with San Joaquin <br /> County Ord! ces, Rules and Regul ions,and all applicable California State Laws. L (� <br /> Signed x �_ Title/Company Geo(o i L FIR_ <br /> Print Name J F�D I Y Jd i� Dale_-------I �n 6 <br /> DEPARTMENT USE ONLY` <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> -x <br /> WORK PLAN DATED: 8 —O <br /> Application Accepted By <br /> Date Issued Qi. <br /> Grout Inspection By Date Flnal Inspection By_ <br /> Destruction Inspection By Dale <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 240/ l31S6 �o y SR#DO <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to Sign permit_Encroachment dooc_ <br /> EfLD29-fi2-001 G.i/ Ofd• 33L L ✓ <br /> 6/22/04 <br /> lo.i7-a 6 <br />