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� San Joaquin,County FILE COPY <br /> � ` -,�-I. <br /> Environmental Health DepartmentH.ECE �l_=:' 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/eh@CT2 J -U� UNIT IV <br /> P <br /> Well Permit ApPlication EVUlR }NP..E;� ti€fiI (iI <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PER it I/JEi5YCES <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 /> t� d I- ' 1 Assessors /Dn <br /> WELL Location l7 0 D c1Li�+C /14'e. Cross Street A T City oc F'M Zip 9570? Parcel# OR I�h 4X <br /> PROPERTY /� <br /> Owner �' A(�./CII City Zip Phone# <br /> C-57 Contractor SOecT r1,nyh Eir'lojLl.tAddress_ 3 pW1e I.o_ Dt city S�ocNmn Zip��OSLialSI_ '1_%LPhone#- <br /> Consultant/Sub cntr Lf9 Address 190City m 1 C.Lic# Phone#(HIS�6S�-`1s 00 <br /> GIS Coordinates:X,N-0j0_LL__,Y 12.1 JL Township Range Section <br /> WORK TO BE PERFORMED: <br /> ,ANEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> WELL# OPRESSURE GROUT <br /> `Other 1 ` GROUT SPECIFICATIONS <br /> COMMENTS: L 7,r{, y JgT..r O�Q''C 'I)-.• Inov.�-S e+"F �O ! M O �t7 /�/� <br /> t <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING `'HOLLOW STEM DIA.OF BOREHOLEI.21'O MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:_2._0_` <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 'PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 4m Se. TREMIE TYPE TO BE USED: J(AUGERS 0 HOSE <br /> 'RAIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS C egrt r ,-1- S I v e4 <br /> 0,OTHER: D OTHER APPROX.BORING DEPTH d BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> Wells <br /> ff II� nt�CONDUCTOR CASING PROPOSED No (if YES,list specifications in comment section) <br /> COMMENTS: Wells to 6 t7se tOr /1''I[irn' 'D wells. <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 his application and that the work will be done in accordance with San Joaquin <br /> County Or antes, Rules and Re lations, and all applicable California State Laws. <br /> Signed �---�� sTitle%Company lT_ (_(Y_h'r4 �/1�}� <br /> Print Na �1 . ,�Jr Date l leg / <br /> DEPARTMENT USE ONLY <br /> � p <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued R'2A e/ <br /> / <br /> Grout Inspection By Date/ T�/ /j - <br /> al Inspection By patLo 4 <br /> Destruction Inspection By ate .y <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# - FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> yQo� you 2.36 /a.LS SR# ys� <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign Permit_ Encroachment do /✓ a <br /> EHD 29-02-001 <br /> 6/22/04 <br />