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U IN <br /> oAgo Yan Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> P UNIT IV <br /> Well Permit Application 1 PM >:1 A <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED SAN jO A C U IN' COU.N t 1 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. Thi != i e with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental HealltfTJE � e ' <br /> Assessors <br /> WELL Location X:7 7TRAe-Y"BlEbross Street L.T/%-City 1 IGAGY Zip 9W -Parcel# _ J3-?o 7M"3 <br /> PROPER 5A-VE /M:A L{r 61ZMAR-K� 17 D. g r�C q17 Y M voIFsTd, cwt Y�3 S•2 <br /> Owner _ Address �1 City ._ Zi�hane# —.199 9` <br /> 55- <br /> C-57 Contractor ( [[OILXe✓ ,.Address 3to.� t^67-6iA City 24 Gtd ZipT✓YVc.2Lic&-/svahone# I6-02uxl9 <br /> Consultant!Sub CntrAddress ;J�JZ ( LCICi - Ciiy,PA&rj& Lic# Phone# q/6-5�6f�D�/aJ <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> MEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') a DESTRUCTION (choose type below) <br /> a SOIL BORING* 0 OVER-BORE. DIAMETER <br /> `LWELL#� 10-9 PRESSURE GROUT <br /> O'Other } GROUT SPECIFICATIONS <br /> COMMENTS:_ 9rwe; t I r9y --- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS )� <br /> MONITORING OLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS i-L0 TYPE OF CASING: 0 STEEL WVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ffAUGERS p HOSE <br /> 0 AIR SPARGE/OZONE []PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE'FALL DEPTH IS 30') <br /> 0 SOIL BORING []HAND AUGER GROUT SPECIFICATIONS lAro� CG+reAe <br /> .0 OTHER:_a OTHER APPROX.BORING DEPTH "SD �W130LTED TRAFFIC BOX or 0 STO VE PIPE <br /> CONDUCTOR CASING PROPOSED O-b (if YES,list specifications in comment section) <br /> COMMENTS: '0-5-6 l I <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 Ordi ance Rul�anRegulations, and all applicable California State Laws. <br /> Signed x fy�] Title/Company <br /> Print Nall; Date�9?__ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV F LE, ADDRESS: 2-•1 <br /> :WORK PLAN DATED: �T <br /> Application Accepted y_akDate Issued A ry.a <br /> Grout Inspection B Date O Final Inspection By Date <br /> 107� <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> SR <br /> C-57— WC_-__--WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6122/04 r <br />