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OPQ uVi C • <br /> 2 J o San Joaquin County 0 C7 � <br /> t ° ,? Environmental Health DepartmentLJJVr'I� <br /> ` 304 East Weber Avenue, 3rd Floor, Stockton, SITE <br /> (209)468-3449 Fax: (209)468-3433 Web: wwnv52DZ LUUb MITIGATION <br /> oRN`P or eh_d <br /> `'�p ' �'dr��i�%",LT,h UNIT IV <br /> Well Permit Application c :n <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED }'/inrJ <br /> Application is hereby made to San Joa <br /> yquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin Count Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL LocationDevelopment <br /> glR k;s • 11 S+ < Q <br /> Cross Street i. City ✓(7j y�) q�]`` Assessors <br /> PROPE((��Try1' //' �7 / 1 Z'P JI4_Parcel# <br /> Owner MC. l•Qatn50y 11� A-�Cit <br /> Address ( �/ / <br /> C-57 Contractor �Q y J Zipl7dt!Phone# 31-6 Z, b <br /> Address •P• P t7764. LiJ? � <br /> Consultant/Sub Cntr � // 1,, City O I Zi Phone# / <br /> // OU Address��Z. ,My(r pft L,c# 9 <br /> GIs Coordin3t 3} 7� or City R� Phone# rd—�3 5' <br /> — 17'1, 7 t275,Township <br /> WORK TO BE PERFORMED: Range—Section_ <br /> 0 NEW a SOILWELL/BORING (CPT,GEOPROB ,HYDROPUNCH,H ND-A G R OTHER`) DESTRUCTION 0 WELL# RING#Sltfiy � Q��_ g_ _ {� ��TPq(rf'� 1 OVER-BORE. DIAMETER <br /> se type below) <br /> O'Other CA4 I I11f u PNq PgR aE GROUT <br /> COMMENTS: L ,1 V GR, UTSPECIFICATIONS— <br /> ICAT <br /> TYPE OF WELL INSTALLATION TYPFfLI� <br /> 0 MONITORING fl��• CONSTRUCTION SPECIFICgTIONSIV <br /> HOLLOW STEM DIA.OF BOREHOLE <br /> 6 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS MULTIPLE CASH MULTI-LEVEL WELL CASING DIA: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALT -b C r,1,� CASING: 0 STEEL 0 PVC BOTHER: <br /> AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Dyes KTREMIE TYPE TO BE USED: 0 AUGERS <br /> HOSE <br /> IL BORING 0 +No (NOTE: MAXIMUM FREE-FALL DEPTH OIS 30) <br /> 0 HAND AUGER GROUT SPECIFICATIONS <br /> OTHER: 0 OTHER APPROX. BORING DEPTH (f h.p <br /> COND CTOR CASING PROPOSE a 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> COMMENTS: (if YES,list specifications in comment section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby c fy th I ha prepared this application and that the work will be done in accordance with San Joaquin <br /> County Or - anc Rul s and Regulations,and all applicable California State Laws. <br /> Signed x Title/Company <br /> Print Name <br /> Date L'l <br /> b1.x DEPARTMENT USE ONLY <br /> SITE MAP IN 6llgl/GW FILE, ADDRESS: j�') <br /> WORK PLAN DATED:_g I I IDS <br /> Application Accepted By 1A*Znn s" <br /> Grout Inspection By Dale Date Issued_ 4 114 /py Area 2( <br /> Destruction Inspection By Final Inspection By Date <br /> Dale <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 /> xl`\o I ju $9.co 12511!y 4l14/oy SR# <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sin Permit— S <br /> EtID 29-02-001 9 P Encroachment doc <br /> 6/22/04 <br />