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,ate n Joaquin County <br /> Environmental Heafth Department SITE <br /> 600 E. Main Street, Stockton;CA 95202-3029 MITIGATION <br /> 9j4 t3�l49 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> �<,F�•R� �. - U 1L��, Well Permit Application UNIT IV <br /> ��}} <br /> 2 *AAFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED <br /> Application is hereby made to San ), qufor a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Devp1 }t� tip ,.3 and the Standards of San Joaquin County Environmental Health Department. <br /> ' 55 treetNA Rtav AssessorsWELL Location VI~ lLar'l �_ <br /> City T k 4 C`( Zip 9 0 4 b Parcel# <br /> PROPE TY r u`� T C t�Lz tte-r 40n V e- 7-rA c. <br /> Owner ,. Address , - City J� Zip C/one# <br /> LI, WI: IL , <br /> C-57Contractor��#pXD%11IiT Add,OF09 PLEA&Ah1 VAEIf`t'�ityPigC R�illl ip..9_ 6 Lic#983T Phone $QO ,9 $- 355 <br /> Consultant/Sub Cntr l V 1 <br /> INCAddress R S M D $ City R 1 1`I _Lic# 6 Phone# J a $g I-2�9 <br /> GtS Coordinates:X- Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL I BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER`) I DESTRUCTION (choose type below) <br /> 0 SOIL BORING# <br /> a WELL# MOVER-BORE, DIAMETER $?—INCH, _ <br /> 0*Other p PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS:_'P1 TAVCTION 0$ ;P�MVNITORIN& WECLs yam_ IIT(jt^ <br /> TYPE OF WELL INSTALLATION TYPE- . CONSTRUCTION SPECIFICATIONS � <br /> f MONITORING a HOLLOW STEM DIA.OF.BOREHOLES!! l]MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS SCI- 40 TYPE OF CASING: .0 STEEL . I PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 3f TREMIE TYPE TO BE USED: p AUGERS 0 HOSE <br /> D AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes i No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) ` <br /> a SOIL BORING p HAND AUGER GROUT SPECIFICATIONS N E A T C C M t N T <br /> .0 OTHER: 0 OTHER APPROX.BORING DEPTH '20 f 0 BOLTED TRAFFIC BOX or <br /> 0 STOVE PIPE j� <br /> CONDUCTOR CASING PROPOSED NA (if YES,list specifications in comment section) <br /> COMMENTS: - D t S fi R V C T 4 U N 0 t 1 MON IT D P I N k W t L L,S,,,,.__, <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, Rules and Regulations, and all applicable California State Laws. <br /> Signed x_ 1� '' c...�.V�t 1.. _ Title/Company P R t S!—01 8 L � I(Z A M-4 Glt 0 V 1 ft v N I h L t I N(;, <br /> Print Name To$._r N - "II Q M 4 C- _.. Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: S•d3 —Fc -k, S4 <br /> WORK PLAN DATED: <br /> Application Accepted By vv- Date Issued to 1 23/O Area <br /> Grout Inspection By Date tt Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHI'_CK A REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 35vZ $OedO <br /> dSR# ✓�S}S 5'` <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permits Encroachment doc_ <br /> EHD 29-02-001 web i <br /> 6/22/04 <br /> - I <br />