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k <br />� } ... HT <br /> San Joaquin County <br /> Environmental Health Department <br /> P <br /> { 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 SITE <br /> MITIGATION <br /> "— (209) 468-3.449 Fax: (209)468-3433 Web: www.sigov.org/chd <br /> UNIT IV <br /> A�lFpFzN`P <br /> Well Permit Application � � 23 3� <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FR.OM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work di5sc qb s iThis' #A r <br /> � � A r t+ono"de in compliance with San <br /> Joaquin County Development Title.,C pter 9-1115.3 and the Standards of San Joaquin County Env[QnrvPntal'sllht partment. <br /> WELLLo pGfC� (} � Assessors <br /> _Cross t ~ Cif Zi�P—�Parcel# <br /> PROPERT�] r <br /> Owner /7' Address —lC�ityy Zip �•��hone# 91— 11 7 <br /> C-57 Contractor N" 7S City p �� J� vt'h6ne# C3� t(J <br /> Consultant/Sub Cntr 4-6 <br /> Address. City Lic# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED- <br /> 'NEW WELL 1 BORING (CPT,GE.WB OBE,HYDROPUNCH,HAND-AUGER,OTHER`) []DESTRUCTION '(choose type below) <br /> 011-BORING# <br /> LL# - 1]OVER-BORE, DIAMETER <br /> O'Other 0 PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICA 4ONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE "'�t <br /> D EXTRACTION ULTIPLE CASINGS .d MULTI-LEVEL WELL CAS]NG DfA: <br /> AIR HAMMERIDRIVEN CASING THICKNESSGV <br /> ��•TYPE OF CASING: Q STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL -EM1E TYPE TO BE USED: 0 AUGERS d HOSE <br /> 0 AIR SPARGE/OZONE USH POINTSg�2r CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOT MAYf UM F EE-FALL DEPTH IS 30') <br /> -OIL BORING 0 AND AUGER GROUT SPECIFICATIONS_.. <br /> (� THER: r I]OTHER APPROX. BORING DEPTH_ B BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> COMMENTS: <br /> ! CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> - r <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 Ordinances, RuI and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company A6 <br /> Print Name r t/1 - <br /> Date <br /> DEPARTMENT USE ONLY ` <br /> SITE MAP IN UNIT IV FILE,ADDRESS: y4 fit CZ <br /> WORK PLAN DATED: <br /> Application Accepted By r Date Issued Z b` <br /> Area_ �6 t,( <br /> Grout Inspection By Date Final Inspection By Date 'tb <br /> Destruction Inspection By Date <br /> COMMENTS!CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <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 />