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• • FILE COPY <br /> San Joaquin County <br /> I=. y Environmental Health Department SITE <br /> " X, 600 E.Main Street, Stockton,CA 952172-3029 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.otg/ehd UNIT IV <br /> a, Pi <br /> Fo Well Permit Application <br /> 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,Chap r 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> rZO A� C). 1 -) Assessors� i ���Q <br /> WELL Locatio 88 ✓ Cross Street c��f�/u+n ��)City �rn� Zip � Percel# �✓/ <br /> Owner N✓ � Address f V Cit ip Phone# <br /> C-57 Contractor— 'I", Address 10 t� frI-t� C Sc1t. A ZI �qI Lic21� yPhone# <br /> Consultant/Sub Cntr Address ipZ2 MISAry1 City W`InuO Lic# Phone# <br /> 11 nn II <br /> GIS Coordinates:l�`T N� ,Township 710 Range `I Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGEK,,OTHER') p DESTRUCTION (choose type below) <br /> p SOIL BORING# /���I �� 0 OVERBORE. DIAMETER <br /> WELL# �1r-'/e't�Y /,W„W// { 0 PRESSURE GROUT <br /> 0.Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 'MONITORING `,[HOLLOW STEM DIA.OF BOREHOLE,„ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 8 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS ' b. O TYPE OF CASING: p STEEL )(PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ' l;7 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS C PW�-'t vI �)7? <br /> 0 OTHER:_a OTHER APPROX.BORING DEPTH ` c - :(J(,' 0 BOLTED TRAFFIC BOX or ASTOVE PIPE <br /> CONDUCTOR CASING PROPOSED -T(;(') (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 Ordina ces, R les and Regulations, and all applicable California State Laws. ,fy <br /> Signetlx '-' Tme/Company [/I'V S;to�/�s� 4m•4 [;'�e /L•, <br /> Print Name e' me' 7 Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: /7y Sc ✓h <br /> WORK PLAN DATED: —� <br /> Application Accepted By Date Issued rea� <br /> Grout Inspection By Dale Final Inspection By �� "�7 <br /> Destruction Inspection By Date mom <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> �- a �g32 s. sR# OU X03 z <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_EncroGeMent doc_ <br /> EHD 29-02-00i web <br /> 6/22/04 ��i <br />