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San Joaquin County <br /> Environmental Health Department <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 SITE <br /> ' (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/1} MITIGATION <br /> NIT IV <br /> o <br /> Well Permit Application 2005 APR . 5 'Pi ^��3 <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATEII � VO (}¢¢ C-OUNtY <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work des #� 1 <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Envir I a e�tra5 compliance with San <br /> WELL Locatior�( � Street Q32 <br /> G �j Assessors <br /> Zip parcel# <br /> PROPE ,r o + if <br /> Owner 41A Address�g N. iN i 4 <br /> City.ll�{�Q� 1 Zip7, or-phone# 5 ! 2-1 <br /> —� f` <br /> C-57 Contractor Address City I! Zip Lic# Phone# <br /> Consultant 1 Sub Cntr rj S <br /> Address iql Phane# 7l 6 <br /> GIS Coordinates:X Y TownshiI e <br /> P Range � Section <br /> WORK TO BE PERFORMED: i <br /> s W WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) Q DESTRUCTION choose type below ! <br /> Q SOIL BORING# <br /> WELL# yp ) 1 <br /> 1E � D Q OVERBORE. DIAMETER <br /> Q*Other E C � Q PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: i� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SP CIFIC IONS it <br /> 1IGONITORING AtOLLOW STEM DIA.OF BOREHOLE �17ULTIPLE C'ASINGSi Q MULTI-LEVEL WELL CASING DIA:19% <br /> Q EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESSA- P I <br /> N TYPE OF CASING: Q STEEL Q FVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH <br /> OF GROUT SEAL 15r�' TREMIE TYPE T <br /> ., �F OBE USED: Q AUGERS Q HOSE <br /> Q AIR SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes R'(o NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS II <br /> Q OTHER: a OTHER APPROX.BORING DEPTH i BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> k <br /> CONDUCTOR CASING PROPOSED ¢ iP(if YES,list specifications in comment section) 1 <br /> COMMENTS. �I <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> G� it <br /> I hereby certify that I have prepared this application and that the work will be,done in accordant with San Joaquin <br /> County Ordinan , Rules a d e lations,and all applicable California State La ` <br /> f <br /> Signed x Title/Company <br /> t i <br /> Print Name 1 I Dat <br /> DEPARTMENT USE ONLY �k <br /> SITE MAP IN UNIT IV ' (73 � � —� <br /> FILE,ADDRESS. 1�+�/� Q <br /> WORK PLAN DATED: D I A ¢I b <br /> Application Accepted B _ <br /> PP p Dale Issued }� A Ir� t 1 1 2005 Area 1 4„�9 <br /> Grout Inspection By Date Final Inspection By to <br /> /12 <br /> Destruction Inspection By Date i it <br /> COMMENTS I CONDITIONS: - r <br /> ACCOUNTING ONLY: AID# FAQ, <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE f PERMIT/SERVICE REQUEST# INVOICE <br /> 35'01 89. ao a l sR�K Q04182- 3 <br /> C-57— WC--WAIVE=RC-57 letter of Authorization to sign permit Encroachment doc� <br /> EHD 29-02-001 <br /> 6122/04 ! i <br />