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San Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> f (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> -6 Well Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED2006 SEP 14 AM 1114 <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 Environmentajl IV,e4t4 C u N T Y <br /> /�/J 9 EN,I V!3"ti C)f�?1`i C:/��fsi`e�'sbrs <br /> WELL Location /����� /U, � 1� Cross Street � �� City � kJ "� ik T H Q E P,�PbkblfNT S.f.Cv Rt�}( w� <br /> PROPE TY I- 95,237 G� <br /> Owner L_d C/f C le c c/ Address /7 7�i S /y�/1, k,+/City h6 c/1e_<G Zip Phone#;09 7a2 7- S`03 5 <br /> V°{ Uy 4 PG ig V GI/6 S [z 9s"(�� <br /> C-57 Contractor r .,r� Address —City � �� Zip Lic# 72C90hone# UG' -777 tl/Er+Q <br /> Consultant/Sub Cntr Address City Li c#_71 07JO( Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 11NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> ,44vVELL# /YL((�C l ��l. / W'2- n1 KJ-`f 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: 6(L- /� V't i')< --- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING YHOLLOW STEM DIA,OF BOREHOLE/ ' 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SC_� tlfJ TYPE OF CASING: 0 STEEL . <br /> QVC OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL II-Sl TREMIE TYPE TO BE USED: AUGERS g4OSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Ye G No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH OLTED TRAFFIC BOX or TOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: -7' Y 11-S tr. l U' a 040 �L•t�c.L�y� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Or 4nces, Rules and ecllations, and all applicable California State Laws. / <br /> Signed x iLC ' Title/Company <br /> Print Name ^' a kni 4 Date goo, G <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: .��^ 2000 r/��✓Qc1� <br /> Application Accepted By a t1M - Date Issued /? C —Area ??'7 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: _7 • 70, °T 777k Zi c <br /> ACCOUNTING ONLY: AID# 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 />