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San Joaquin County <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 /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 /> Assessors A � <br /> WELL Location ro"�4 R Da d3 Cross Street�/j �Ip t City �SCa 6- Zip Parcel# <br /> PROPERTY J v t Address /O /7d�� (�"`t City ocy� Zip �S ZoI Phone# ZD`1-q6g-300() <br /> Owner / z _ <br /> C-57 Contractor ���� f` 1 1�r Address qS 0 ff0 u1- �d- City (Rf Zip SSJ Lic# `l0 7 Phone# L7 3)3-3100) <br /> Consultant/Sub Cntr KrIltIeLl Address 622 City U� qr� Lic# Phone# y/S _Zy Z�SO <br /> GIS Coordinates:X '- I Z 1,04S ,Y 13.20k6 Township I S Range Section 136. <br /> WORK TO BE PERFORMED: <br /> NEW WELL/ BORING (cpT,GE�6PIRi9BE, HYDROPUNCH,P tb�AU6EP01.14ER*) p DESTRUCTION (choose type below) <br /> Q SOIL BORING#Qft--5, 0/-01-(Z a OVER-BORE. DIAMETER <br /> lJ WELL# a PRESSURE GROUT <br /> *Other GROUT SPECIFICATIONS <br /> COMMENTS: -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING a HOLLOW STEM DIA.OF BOREHOLE � a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA:------ <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 6 r�TYPE OF CASING: a STEEL a PVC a OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL_90--(t TREMIE TYPE TO BE USED: 11 AUGERS a HOSE <br /> a AIR SPARGE/OZONE 'PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING <br /> D p HAND AUGER GROUT SPECIFICATIONS 1V 2r Q )--A <br /> OTHER: 1 T_ a OTHER APPROX.BORING DEPTH RU 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED_(if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordipfinces, Rules and Regulations, and all applicable California State Laws. <br /> Signed x, �t Title/Company Geolo ist/Kenned Jenks Consultants Inc. <br /> Print Name Mike McLeod, P.G. Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Z l TO l F 'S f--R I - 17 t) <br /> WORK PLAN DATED: 8- Its 10,E <br /> Application Accepted By Date Issued Z z�0�i- Area <br /> Grout Inspection By lil�nnn�+,n Date en,.. <br /> 3 O Final Inspection By�+,%e-C� Date O <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# A <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ala SR# 4 qLf <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />