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,�`' San Joaquin County <br /> � �D <br /> ?� Environmental Health;Department MC '11 ITE <br /> r y ,f�! <br /> f. 1304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)4b8-3433 Web: www,sjgov.org/ehdDEC <br /> ° `� ' 2 2004 UNIT IV <br /> Well Permit Application FNVIRp _ <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERM�iT/SEF? HEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This appli SonRi VICde in compliance with San <br /> ES <br /> -1115.3 <br /> Joaquin County Development Title,Chapter 9and the Standards of San Joaquin County Environmental Health Department.,.. <br /> WELL Location s Gross Street S Assessors " r <br /> Z1/l City L G zip Yi Parcel# <br /> PROPERTY <br /> Owner C"+ I Y� Address 9Z5 AJ �� p c� <br /> G.JCity Z1lDq�L.l73Phone# 7 3 7 0 �f <br /> C-57 Contractor Addres <br /> dk2 CJyvl�� �,�_ . <br /> City �Zi � "c#a� phon57 6y 1 <br /> e#QJ��D .�D 40 Q <br /> Consultant/Sub Cntr <br /> Addre S <br /> fl Cst .s . <br /> y K-Lica phone#-e6moo']/C1&;(, <br /> GIS Coordinates:X Y Townshi <br /> P Range Section <br /> WORK TO BE PERFORMED: <br /> OEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') Q DESTRUCTION <br /> 11 SOIL BORING# (choose type below) <br /> ASNELL# Q OVER-BORE. DIAMETER <br /> [I'Other [I PRESSURE GROUT <br /> COMMENTS: GROUT SPECIFICATIONS 1 <br /> TYPE OF WELL 1NSTALLATIOrl TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING OLLOW STEM DIA.OF BOREHOLE& I 1 f <br /> 'Q iMULT1PLE CASINGS Q MULTI-LEVEL WELL CASING DIA;� k <br /> Q EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS!TYPE OF CASING: Q STEEL p PVC BOTHER: <br /> Q VAPOR <br /> Q MUD ROTARY DEPTH OF GROUT SEAL .3b *:Z�TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> �R SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p,Yes ZNo NOTE- MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS <br /> Q OTHER:_g OTHER APPROX.BORING DEPTH__' r 4=Z OLTED TRAFFIC BOX or n STOVE PIPE <br /> c <br /> COMMENT5: CONDUCTOR CASING P OPOSED (if YES,list specifications in comment section) <br /> s <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. t <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the;wrork will be done in accordance with San'.Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signedx „�,� — <br /> Title/Company <br /> Print Name ! SC <br /> ' Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ��y 125 'llJ✓` ST - _-_ <br /> WORK PLAN DATED: <br /> 7, <br /> Application Accepted By to Isisued <br /> Grout Inspection By to incl Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITION <br /> ACCOUNTING ONLY: AID# lItACbW <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# R 'D ,11 DATE PERMIT!SERVICE REQUEST# . INVOICE <br /> > lp,,, j 5R#. <br /> I <br /> C-57— WC--WAIVER C-57 Letter of Autho a n t sign permit_Encroachment doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />