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D*P0 F� v ED *San Joaquin County • <br /> 6 1005 Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> ENT HE(AON468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> SERVICES 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 Count Development Title Chanter 9-1115.3 and a Standards of San Joaquin County Environmental Health Department. essors <br /> q y �'n,fC� Kt 1X �P-�orvr 3bciq�n Zip G� cel# <br /> WELL Location G-I Cross Street city <br /> PROPERTY y,_ /r' ��}.�r` t 0fa&t <br /> Owner \''{ lW C�O-A•-A Address OLS NC� City_'Sf'Oc(yCC,�DI�A}Zip�vd�'`P cne# <br /> C-'�j.J('� Uf•n Address *' u.�l JOG.1d city v11'L`�iip IJ`^ ic# <br /> C-57 Contractor � n_A !I� _ �� C �-lN� ��.y� (� l n <br /> Consultant/Sub Cat, I 1 u� M Address ��m�� -" �nY` y � Lic#���'F'hone# `(S —�u � `V 1( <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: \ , E <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) Na OVER-BORE. I (choose type below} <br /> SOIL BORING# HOVER-BORE. DIAMETER <br /> I7 USURE GROUT <br /> �WELL# GROUT SPECIFICATIONS p� <br /> *Other, �� <br /> COMMENTS: S V't L L) CYl�J— l.%(L <br /> of 1Wapt N v"� <br /> TYPEOF WELL INSTALLATION TY E STRUCTION SPECIFICATIONS ^ I <br /> ONITORING a HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> E CA <br /> EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: p STEEL 0 PVC O OTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS a HOSE <br /> []AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> OTHER:_0 OTHER APPROX.BORING DEPTH a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (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 Aaquin <br /> County Ordina a Ru an Regulations, and all applicable California State Laws. f - <br /> Signed xT / Title/Company <br /> Print Name 1� 'P67• 016 _ _ Date <br /> DEPARTMENT USE ONLYA <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: I <br /> Application Accepted By Date Iss ! Z re <br /> Grout Inspection By Date <br /> Destruction Inspection By I to <br /> COMMENTS/CONDITIONS: HW-t PIM, <br /> ACCOUNTING ONLY: AID# -e`f d1M FAC# 7 <br /> PE CODES FEE INFO AMOUNT REMITTED CHEC # R 'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> e'o 3 D SR# Af I 6 <br /> C-57_ WC=WAIVER_ C-57 Letter of Autho izat' sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />