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• • FILE COPY <br /> San Joaquin County - ` <br /> , <br /> Environmental HealthDepartment[PI,LE� SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> " (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/etGC I N J zu I UNIT IV <br /> F Well Permit Application E1NVIROP!'r4 M HE" <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDPERNIMSERVICES <br /> Application is hereby made to San Joaquin County for a permit to construct andlor 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 /> G 8 8 P J I A .N� �� Parcel# ow <br /> WELL Location ��.� L t''fi Cross Street vt Icily Oe Zip 7S�U(((�yyy���P���arc��_elppp#�77��t�,,,,,000,,, <br /> OwnerPROPTY/1, I 51L�N ^^ / , City S'I��'^ Zip Phone# <br /> Owner –/, m Address ��S• N� EI W � ( ) <br /> I p S Elo^ Zi —� �k6 8 <br /> C-57 Contractor SI r,�'1 �pynlorct7MAddres5236S WIIt T wt T city +�� p95�oS Lica S12?6 Phone# `.b s- ?I'1. <br /> Consultant I Sub Cntr LFR Address 1900 bell S}- city cttau lite,Lic# Phone# II S)652-%A50w <br /> .Vj-""` r-loai <br /> GIS Coordinates:X ,Y _ ,Township _ Range Section <br /> WORK TO BE PERFORMED: <br /> ;KNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') D DESTRUCTION (choose type below) <br /> 0 SOIL BORING# DOVER-BORE. DIAMETER <br /> jj�WELL# -I0 .e- �8ti. 0 PRESSURE GROUT <br /> b*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING ',HOLLOW STEM DIA.OF BOREHOLEI-21'O MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: 2.0 <br /> D EXTRACTION D AIR HAMMERIDRIVEN CASING THICKNESS ^pTYPE OF CASING: 0 STEEL 'PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL -I'u ^�rIY'a.-! TREMIE TYPE TO BE USED: ,RAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED: D Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> D SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS C ew.lic+ S I v,r.v <br /> )(OTHER:_0 OTHER APPROX.BORING DEPTH 657 't- 90" D BOLTED TRAFFIC BOX or a STOVE PIPE <br /> (�CONDUCTOR CA ING PROPOSED No (if YES,list specifications in comment section) <br /> COMMENTS: Welk 40 6E V`Sej y�Cr �r^ t e6 ''c., 6.1 elS- <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereAcetthat I haveprepare his application and that the work will be done in accordance with San Joaquin <br /> Counttes, Rules and Re talionsand all applicable California State Laws. 11nnSigned x Title%Company CT-e - toRkA (,IF KPrint Na6, Date I <br /> DEPARTMENT USE <br /> /ONLY �\V <br /> SITE MAP IN UNIT IV FILE,ADD ESS: - E ?9jfLa #7 Zq (�6ICVP-W 4C-6 <br /> WORK PLAN DATED: 2 —O <br /> Application Accepted By Date Issued ��l! ' Area 46 PX <br /> Grout Inspection By ale11�Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 2Ro I Mw 8q ' 2 5 a <br /> SR <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorizotion to sign permit_Encroachment doc—rmu -4 <br /> EHD 29-02-001 <br /> 6/22/04 VVJ&-4 07-2-1W <br />