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'AWn Joaquin County 1�F�C F <br /> ifi­ <br /> Environmental Health Department �1� <br /> -C 600 E.Main Street,Stockton,CA 95202-3029 MITIGATION <br /> (209)468-3449 Fax:(209)468-3433 Web:www.sjgov.orWehd APR - 9 29hIT IV <br /> Well Permit Application ENVIRONNIEW HEALth <br /> NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED PERMiPSERVICES <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 /> C T ���1,�P� !'l Assessors <br /> WELL Location M) 6 l�J�/ Cross Streetlx � City r V Zip�v,ParceHF <br /> PROPERTY ��,,,,,���,,tV M�X ({3L1 CItyc lip Phone#d�i-3�(�-1(000 <br /> Owner LVS�bC�,{a1�1�11I1-� ddress 4'�C� ;'1� p7—r 1'� + 1 .��,[� �� �,w� <br /> C-67Contmdor blW 1Y-(- Address T� CIpXGG�I 1t�r City ZipCl Lic#lu'�' Phone# rn_ GL91w <br /> Consultant]Sub Cn /k� I V 11( Addrej) W k 1✓7`�-- City!,IACC V(' Phone#r <br /> GIS Coordinates:X <br /> y_,TownshipRange_Section <br /> WORK TO BE PERFORMED: <br /> KNEW WELL/BORING (CPT,GEOPROBE,HYDROPU NCH,HAND-AUGER,OTHER? OE ER UCTIRE. DN MEh (choose type below) <br /> a SOIL BORING# a PRESSURE GROUT <br /> XNELL# GROUT SPECIFICATIONS <br /> a*Other <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS Ott <br /> ,MONITORING HOLLOW STEM DIA.OF BOREHOLEO MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: +� <br /> 0 EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS;�� 14 TYPE OF CASING: g STEEL XPVC p OTHER: <br /> VAPOR u MUD ROTARY DEPTH OF GROUT SEAL &O 1 TREMIE TYPE TO BE USED: 0 AUGERS HOSE <br /> AIR SPARGE/OZONE g PUSH POINT(GP or CPT)GROUT SEAL PUMPED: XYej -U Ng (NTE: MAXIB UM FREE-FALL DEPTH IS 30') <br /> n SOIL BORING 1]HAND AUGER GROUT SPECIFICATIONS_ <br /> Jf l2-VY1QL' r <br /> D OTHER:_D OTHER APPROX.BORING DEPTH (Vy OOLTED 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 /> I hereby certify that I have prepared this application and that the work will be done i1 accordance with S Joaquin <br /> County O d' an es, ��, s and Regu ons,and all a able California State Law <br /> Signed x r <br /> Tdle/Company <br /> �} v' <br /> Print Name y 11 l � 1 Date <br /> DE RTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 6-1-KC,�C ✓R�/�G� <br /> WORK PLAN DATED: t/*� a <br /> Date Issued 7/J/D / Area 9� <br /> Application Accepted By U Date_ <br /> Grout Inspection By Date Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PECODES FEEINFO AMOUNTREMITTED CHECKS REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 85- d1D 1/ v9 S' aoS�gr <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001web <br /> 6/22/04 <br />