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San Joaquin County <br /> '"'"� ' f �,TH,EA1 1 SITE <br /> s Environmental Health Depa��t#{ial��'J��E�_€°d i f I�hL.T;-� <br /> ` ��,�& ,. Er''' r'1 `') MITIGATION <br /> 304 East Weber Avenue,3rd Floor,Stockton, �/u� �;;," <br /> I (209)468-3449 Fax:(209)468-3433 Web:www.sjgov.orWehd <br /> UNIT IV <br /> is 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 <br /> WELL Location 1 o ;(o No:,-ke Okr1�4t0 Cross Street 9ovncct`ts-Vkcity Sk„c_Ltjo%l Zip Parcel# <br /> PROPERTY <br /> Owner It,ssett Address NZa3 (U. CA'c,tOv, eCitys'-OC V__kMZip .� 6 Phone# f it `7+66" 4'S- <br /> C-57 Contractor LSP D'� (\ Address c150 1Jta W C CityV`l4 I%Ae Zip 5455 Lic# JI Phone# <br /> i <br /> Consultant fSub Cntr00&L,'CC_ S011A0vS Address 'LIS l _Cx0.1vk5City C6 Co Lic# Phone# 116-4GO`35:`f <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> Q NEW WELL!BORINGCPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") Q DESTRUCTION (choose type below) <br /> _SOIL BORING# p OVER-BORE. DIAMETER <br /> Q WELL# Q PRESSURE GROUT <br /> Q'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> N. <br /> TYPE OF WELL INSTALLATION TYPE C NSTRUC71 N SPECIFIATIONS <br /> Q MONITORING Q HOLLOW STEM DIA.OF BOREHOLE Z (]MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: RI <br /> EXTRACTION <br /> Q Q AIR HAMMER/DRIVEN CASING THICKNESS N TYPE OF CASING: Q STEEL Q PVC BOTHER: <br /> VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL W/A- TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> Q AIR SPARGE!OZONE_VUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes Q No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS 11 CG,'r Ce vv.CK-k- J <br /> Q OTHER: Q OTHER APPROX.BORING DEPTH S Q BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED t k- (if YES,list specificalions in comment section) <br /> COMMENTS: <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 this application and that the work will be done in accordance with San Joaquin <br /> County Ord' es u S lations,and all applicable California State Laws. G <br /> Signed x Title(Compan vo n 00 V I I YDS <br /> Print Name `571 F��i �M��� I Date h <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: /7(OCA <br /> WORK PLAN DATED: IQ 4e �/D <br /> Application Accepted By Date Issued Area <br /> 2q 7Z <br /> Grout Inspection By. Date (&Z Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: S� <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> o - 6q SR#OD loci <br /> C-57— WC_-WAIVER, C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6122/04 <br /> PIS 3 s- �--�� � <br />