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F <br /> �qr L,� � FILE COPY <br /> y aa•.a� San Joaquin County ifl,' <br /> r ° Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95202 ;6Yii' C'1 'MITIGATION <br /> L' "' (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.orp/eh.l UNIT IV <br /> at/ .R ✓ Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES I 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 /> Joaq in ounty Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. /� <br /> LU+'ot ' U.9 5S S• Aa.,o&w y 4� p 4'5377 Parcel# F MJ <br /> Assessors <br /> WELL L anon toss Street 1�58'o Cil Zi <br /> PROPERTY pp <br /> Owner S-S Ca ±!l AddressIO � �k , ,, t City %Dr � Zip Phone*WA �n o <br /> g'.Jv?ro <br /> C-57Contractor V W Address 70 00� CityLj2L1j__Zip SsW/ Lic# Phone# 34.9-46J� <br /> Consultant I Sub Cntr a ddAddree/ss City Lic# — Phone# <br /> GIS Coordinates:X—IZI•V I> ,Y 3�- )T Township Range Section <br /> WORK TO BE PERFORMED: <br /> XNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> a SOIL BORING# a OVER-BORE. DIAMETER <br /> $WELL# WC S WC.-t W $ 'j _fl0 aPRESSURE GROUT <br /> a*Other A GROUT SPECIFICATIONS <br /> COMMENTS: exTWCo <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> VMONITORING `ffHOLLOW STEM DIA.OF BOREHOLE$'_ a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:a _ <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS SC.In LCD TYPE OF CASING: a STEEL J PVC a OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 1-50 TREMIE TYPE TO BE USED: ILAUGERS a HOSE <br /> u AIR SPARGE/OZONE p PUSH POINT(GP or GPT)GROUT SEAL PUMPED: jrYes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS VAI Gia t 7 6�c _t PT�� <br /> a OTHER:_g OTHER APPROX.BORING DEPTH BOLTED TRAFFIC BOX or a STOVE PIPE <br /> n CONDUCTOR CASING PROPOSED PO (if YES,list specifications in comment section) <br /> COMMENTS:_y weY-x.S r " -' A-- r, C4—J-4 •-J <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 /> CounWjrdmances,R s and Regulations, and all applicable California State Laws. <br /> Signed I� Title/Company �..�lu-r ;,}sA <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: SO LCO <br /> WORK PLAN DATED: PS O�5 cC �/ Q(� <br /> Application Accepted By Date Issued d : Area UO r <br /> Grout Inspection By Date Final Inspection By ✓� <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 DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 2-go-4 Mut 84•' 2515 -3o sR# O5ylI3 <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD 29-02-001 Q�•Q t I a"2.... <br /> 6/22/04 <br />