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Ian Joaquin County FILE� Y <br /> oG <br /> Environmental Health Department SITE <br /> y: V. " { 600 E. Main Street, Stockton,CA 95202-3029 MITIGATION <br /> •'': 1j = (209) 468-3449 Fax: (209)468-3433 Web: www.Sjgov.org/ehd CPTj UNIT IV <br /> qR Well Permit Application <br /> 2� 1 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �/ D <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 /> _ //11hh ! Assessors Z _ <br /> WELL Location_ �4A 14"f,• s CC <br /> Street w'�^` City tre'C Zip S3�lo Parcel# 3rlS O� <br /> PROPERTY / / N/►� Address fY/ /O Cite 0 one# �+ �I "O v <br /> C-57 Contract(or/C I\ I l�fkA. Address],Q e 2� City -"� Zip 11J13 Lic# Phone#(12 1313 S2�oo <br /> Consultant/Sub Cntr Adld'resslrl ; /� +oyAwra i�City ���^o�jc.o Lic# Phone#(Vif]- <br /> GIS Coordinates:X 3 T 3 Y 2�• T2 J Township zs Range S� Section Z <br /> WORK TO BE PERFORMED: <br /> Lt'NEW WELL/ BORING CP EOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION (choose type below) <br /> pfSOIL BORING# 'L �� 0 <br /> 0 WELL# / 'PRESSURE GROUT <br /> METER <br /> 0'Other GROUT SPECIFICATIONS <br /> COMMENTS:_ ce- ( S <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION O'AIR HAMMER/DRIVEN CASING THICKNESS A/A TYPE OF CASING:. 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL T 7 TREMIE TYPE TO BE USED: ❑AUGERS NOSE <br /> 0 AIR SPARGE/OZONE )3 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Ves 0 No (NOTE: MAXIMUM FREE-FALL'DEPTH IS 301) <br /> 'SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS_ C9--1,4—/ ria-"'•^^�4-C <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH—2--04+ 0 BOLTED TRAFFIC BOX or 0 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 in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x ✓ ^r lz�, �� Title/Company '120) �.,; A\_C As�)1 S <br /> Print Name 'Grey E'�/1y�c vd Date <br /> DEPARTMENT USE ONLY 2q-S Jr <br /> SITE MAP IN UNIT IV FILE, ADDRESS: SO W S 1 <br /> WORK PLAN DATED: q <br /> Application Accepted By Date Issued ! -7 Area V <br /> Grout Inspection By Date Final Inspection By TC'v to <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEEINFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR# DSI d <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc/✓/J <br /> EH 29-02-001 web <br /> 6/22/04 <br />