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� San Joaquin County <br /> FILE CON <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 MITIGATION <br /> 2008 (209)468-3449 Fax:(209)468-3433 Web:www.sjgov.org/ehd UNIT IV <br /> *E. . T HEAL Wi Well Permit Application <br /> PEKn ITl rPMCES NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 9-1,11115.3 and the Standard oaquin County Environmental Health Department. <br /> �,� A6 I/� -4/mak D PC's it '<< Zi 7 Assessors <br /> WELL Location Cross Street y� p 953 77 Parcel#�'Tp%v! <br /> PROPE},2TYs101 <br /> L VJ , ,r • 324 'IN�O <br /> Owner��I^L, �AddrLhs 1 gJby/rc� �c1a(o City ftZipyt3?� Phone# <br /> C-57 Contractor Address Ph 0170 CItyL=2LL zipgiL4L,1111*�hone#36_- S�.oJ <br /> Consultant/Sub.Cnlr <br /> Adddresss — City — Lie# Phone# <br /> GIS Coordinates:X34• u1"�I242-5 <br /> ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) p DESTRUCTION (choose type below) <br /> ff-SOIL BORING#A-C- I AnC-Z, r AC, gOVER-BORE. DIAMETER <br /> a WELL# a PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: L1 So \ loot' -�3 �.�t So` \ S�.�j le-c A-i l loor ..,aS 10 -jp ' o(erzD <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING OLLOW STEM DIA.OF BOREHOLE_& a MULTIPLE CASINGS G MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION g AIR HAMMER/DRIVEN CASING THICKNESS — TYPE OF CASING: U STEEL B PVC g OTHER: <br /> g VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 10' TREMIE TYPE TO BE USED: g AUGERS a HOSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: %Yes g No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> aOOIL BORING a HAND AUGER GROUT SPECIFICATIONS�.t� P7- t / I 1 +- Ca�-rt <br /> THER: a OTHER APPROX.BORING DEPTH 10` a BOLTED TRAFFIC BOX or O STOVE PIPE <br /> OK� CONDUCTOR CASING PROPOSED NIA (if YES,list specifications in comment section) <br /> COMMENTS: AFC I t'�l\� -�o-, QJj k S:�Dta S '. iv �'e Q ra_3V--'A 1-0 5.� �c�2--• <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, Rulesan/dAl�egulations, and all applicable California State Laws. <br /> Signed xs �� L� _ Title/Company v. <br /> Print Name ,If DateCS_—tS -y� <br /> DEPARTMENT USE ONLY <br /> / <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ! ! 4!/-e kk Iv` <br /> WORK PLAN DATED: E dS <br /> Application Accepted By In Date Issued ' Area <br /> Grout Inspection By Dale Final Inspection By Date d _ <br /> Destruction Inspection By Date( <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY I DATE/ PERMIT/SERVICE REQUEST# INVOICE <br /> o �t3 SR# y2� 3 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to si permit Encroachment doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />