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)an Joaquin County <br /> N Envilnmental Health Department <br /> 600 E. Main Street, Stockton, CA 95202-3029 SITE <br /> MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org � <br /> Well Permit Application UNIT <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �t�P� 5 20 IF <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work describ <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Stanch rds of San Joaquin County Environment A1WJAh��oan' q` h compliance with San <br /> WELL Location SEE ATTA H r) Wr)RKPIAN `- ' 0.14- ssors <br /> _Cross Street City Zip Parcel# fieN� <br /> PROPERTY <br /> Owner_ City of_R pert Address 1910 So ith /eL3 <br /> Ay —CRy—BJPDD_ZiP_S-5a6f�_Phone#_SOA-599-91-51- <br /> Consultant/ <br /> Contmctor_zm _Address_R580 o m Road 9 8 <br /> ty---.�_City_Zamora_ZiP_.9�.69$_Lic# Phone#_b30-66 - 8 q <br /> Consultant/Sub Cntr_FCQ O I Fna_Address 3520 8ronk&d Rd Ota 141 Ci <br /> - --0--- —_1t�.Sf09ktOIl_Lic# Phone#_20caa -n a _ <br /> GIS Coordinates:X ,Y ,Townshi <br /> P Range Section <br /> WORK TO BE PERFORMED: <br /> [xjNEW WELL/BORING (CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER`) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# <br /> [xyVELL#_MW-7 MW-A nAI 0OVER-BORE. DIAMETER <br /> (]'Other 0 PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS:_Threa Monitorin n1 Ilc qj' [7-t�.t1 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> [XIAONITORING [x]iOLLOW STEM DIA.OF BOREHOLE_jff__U MULTIPLE CASINGS <br /> 0 EXTRACTION D MULTI-LEVEL WELL CASING DIA:_2_ <br /> OAIR HAMMER/DRIVEN CASING THICKNESS_$LtLgO_T YPE OF CASING: 0 STEEL [zPVC BOTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL_Mb r U1 ferr <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: �.,. O E : TYPE TO M USED: 0 AUGERS [x}iOSE <br /> [x]/es p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS ATTA H D ArORKP AN <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH_9a}EE.t_ <br /> [xI3OLTED TRAFFIC BOX or [x);TOVE PIPE <br /> COMMENTS:_ CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> StovQ p'ngcomole£ d at WeII ML"!0 q��7 na M1� a r <br /> Box <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 Ordinanf/ /Rules and Regulations, and all applicable California State Laws. <br /> Signed x_ / �-� Title/Company <br /> Print Name =�.,,_ �� •j� sTtrK, - / <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> application Accepted By ` L%�I Date Issued (o '� o� <br /> 3rout Inspection By_ Date L r�,( Area X I <br /> h_ mal Inspection 3y Date <br /> )estruction Inspection By Date <br /> :OMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> Z40 - VD, `S °Liv �7 �'(.41i7 .. SR#pb7 <br /> 57 ✓ WC ✓WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> ,HD 29-02.001 web <br /> /22/04 <br />