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• • FILE cur 1 <br /> San Joaquin County <br /> �, ooSITE <br /> z ••o ironmental Health Department <br /> ast Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> N a ; 1 <br /> (209),V8-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> i-16 '.. <br /> ' o SAY <br /> ' P Q `) Well Permit Application <br /> 4� <br /> NEALIH <br /> E rykOrµ�VEt�nu UNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby rr�ue rtY6�h oaquin County for a permit to construct andlor install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health DepartmentAssessors 1163/ <br /> }� -� Zi Parcel# <br /> WELL Locatlon/ IGL.S�G// /C�ro7ss�Street ,/ a1 0� City F^- 4 P <br /> OwOe ERT`L,//Sze 71, Address/7f•") 1�4L1/lcek City r/111c Zlp Phone �j�7 <br /> / / C/ r Address -90>Cy/�o CiIY /' ZIP g1�y/Lic# :Id? rPhoneiN/6 7-1 <br /> C-57 Contractor-- �n p, (� <br /> Consultant/Sub CntrY��✓h`/ Addresr, hye,& City 5 A� Lic#/_ Phone# ?f <br /> GIS Coordinates:X <br /> Y ,Township nz S Range 7 � Section J <br /> WORK TO BE PERFORMED: <br /> fIEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") OE ER BORE.I DIIAMETER a type below) <br /> 0 SOIL BORING# 0 PRESSURE GROUT <br /> JIJVELL# GROUT SPECIFICATIONS <br /> a-Other <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATION <br /> MONITORINGNOLLOW STEM DIA. 11 <br /> OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION p AIR HAMMERIDRIVEN CASING THICKNESS Ste/ TYPE OF CASING: p STEEL gPVC O OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL/S O 3 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/o fig/ <br /> 0 OTHER:_a OTHER APPROX.BORING DEPTH0 BOLTED TRAFFIC BOX or ) TOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> ,5� �t�b)-r9l2 'Gar 2 <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 Ordinances Ruled Regulations, and all applicable California State Laws. <br /> Signed ' Title/Company�7l���P� >)/// <br /> Date <br /> Print Name <br /> DEPARTMENT USE ONLY � ��Z9�5- <br /> SITE MAP IN UNIT IV FILE, ADDRE�S' , _,Sw: �T/�U F— <br /> WORK PLAN DATED: �/ OS <br /> Dale Issued 2�j` �0 Area 0v <br /> Application Accepted By hate <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 DAT PERMIT 1 SERVICE REQUEST# INVOICE <br /> div /Fmos sR# pD Z- 3 <br /> C-57_ WC=WAIVER� C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />