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• 0 FILE COPY <br /> oa4!'•lN.,oo San Joaquin County <br /> Environmental Health Department SITE <br /> "f :< 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 0 N <br /> (209) 468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> Well Permit Application AUCI - ,2 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED BVIROfVf, -`yii M <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This appliphm(rade jn',¢, r§nce with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Stand o San Joaquin County Environmental Health Department. <br /> J �" Assessors <br /> WELL Location L �. 1,t/� iCrossS e �G�n City L^�'`''�a�, Zip �t53)D Parcel# Zl'+-'JOc�- O <br /> PROPERTY <br /> Owner 2i Jrr lyl& 4r, Address � City e Zip K '�30 Phone# <br /> C-57ContractorV 4 V'/ 17��)li�� Address P-O. Peron ql L�v' Citylsl14-0r Zip�W(All Lic#}2Vq04 Phone*(AiOT41- 9(00 <br /> Consultant/Sub Cntr �v�eo, ��+-�• Address 21780 N, 'f.� City 7r" ,Z Lic# Phone# 7-0Y)B'35--06("0 <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> $NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> 13SOIL BORING# a OVER-BORE. DIAMETER <br /> O WELL# �S zb D PRESSURE GROUT <br /> p`Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL IN TALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> RI MONITORING HOLLOW STEM DIA.OF BOREHOLE N 0 MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA: <br /> EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS "� TYPE OF CASING: STEEL VVC Q OTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: B AUGERS 0 HOSE <br /> AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes a No (N TE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS CZ-�— i <br /> OTHER: 0 OTHER APPROX.BORING DEPTH 2'i a BOLTED TRAFFIC BOX or YITOVE 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 in accordance with San Joaquin <br /> County nces, Ru s and Re ulations, and all applicable California State Laws. <br /> Signed x Title/Company �IGB <br /> Print ame Date //A <br /> �QDEPARTMENT USE ONLY 2—q 6r5�' w /0. d- <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �r/C!✓ER GSL/?3✓dS iVCw/i�c T TthCT / S7YG�/ � X /m <br /> WORK PLAN DATED: 8— _p 5 <br /> Application Accepted By Date Issued O J 5 AreaQ22Y <br /> Grout Inspection By ie Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK2# RECD BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 9 Qqe7-1 . 7 3g g os SR# 3 <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 />