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Mss! San Joaquin County j <br /> Environmental Health Departm.ent SITE <br /> ox i 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:wAvw.sjgov.org/ehd UNIT IV <br /> Well Permit Application <br /> Eq NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County fora 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 /> �I _I-" Assessors <br /> WELL Location"ZuZ U C'�le i Cross Street City F t+c t�H �O H Zip Cf rv'3(0 Parcei# 7-0 , <br /> r pIVeJ:n�fsPROPI . <br /> RTY t, <br /> Owner E 101ycp--s A t Vcs T Address Us I C- Fie if I i o L N City(1✓0.+ �t. SZip "tcl 5!,S`Phone# 40 4 ZO ;V4 1.' <br /> C-57 Contractor WOc:IW�✓llClvrl1iY' Address I�J'hcX 3310 Cityi IO iJfS"4gzip145a4Lic#j10�l Phone# -10 <br /> �r+wcvfv;Nci <br /> Consultant/Sub Cntr C e 5 Address F.0 $o i!-x°12$$ City . Lic#CC3140-1- Phone# <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> EW WgLL 1 BORING (CI-T,GEOPROBE,HYDROPUNCH,HAND-AUGER,O ER-) 0 DESTRUCTION (choose type below) <br /> •SOIL BORING ,,''}} 0 OVER-BORE, DIAMETER <br /> 0 WELL.# W i d PRESSURE GROUT <br /> 0*Other EE To !! GROUT SPECIFICATIONS <br /> COMMENTS: in N r r �c4N ` r etrt p�k_' Z-7'2S-ft k <br /> v <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS I { <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE Z- 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTAR DEPTH OF GROUT SEAL ;I TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE!OZONE -jyPUSH POIN (GP r CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') I <br /> ' OIL BORING 0 HAND AUG GROUT SPECIFICATIONS <br /> p OTHER: 0 OTHER APPROX.BORING DEPTH BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> I� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I hake prepared this application and that the work will:be done in accordance with San Joaquin <br /> County Ordi antes, Rules and Regulations,and all applicable California State Laws. <br /> Title/Com an b✓,11't c'+ at Yr t N«� / S <br /> Signed x p Y <br /> Print Named L Date <br /> Y DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final InspectioniBy Date <br /> Destruction Inspection By N Date <br /> COMMENTS I CONDITIONS: ii ! <br /> � I <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DAT i! PERMIT I SERVICE REQUEST# INVOICE <br /> SR# O <br /> C-57� WC_-WAIVER_ • C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-WI <br /> 6/22/04 <br /> li - <br /> ' r <br />