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I <br /> SAN J®AQUIN COUNTY ' <br /> (e�VIRONMENTAL FLEA <br /> LTH DEPA�MENT <br /> 600 East Main Street, Stockton, CA 95242-3029 SITE <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.slclov.oralehd MITIGATION <br /> UNIT IV <br /> 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 Tuttle,,chapter 9-1115.3 and the Standards of San Joaquin County-Environmental Health Department. 2 <br /> Well Location ZQ�33 fVQ�� �*rossStreet _��]RQG,C� City lYQC\ Zip`�� Parcel#AssessorS I�`cJ <br /> Property �T-�� f �/ <br /> Owner i �lr Address p I.r�[�,�f �IV& City 14 Zip.09-376 � �f `r w <br /> ` Phone# <br /> C-57 Contractor f}j,��� C��p� I Address 5M2 Th - -blyd. City demo Lic#l745qZ7Phone(g25 �z1-/�0 <br /> ConsultanflSub'Cntr}�tI I D tg�ddressZJg�j � Q}�VC: City rW[JI Lic#6-915b Phone L �'b�6 <br /> S�zvicts�!,[. <br /> GIS Coordinates:X Y Township Range Section <br /> � <br /> RK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# ❑OVER-BORE DIAMETER <br /> El LL# ❑PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS ? <br /> COMMENTS: <br /> ern pp <br /> I. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS h <br /> ❑MONITORING ❑HOLLOW STEM DIA,OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL :❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USEDXAUGERS❑HOSE <br /> E]AIR SPARGE/OZONE `XPUSH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yes>(No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING til HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: _ TTT❑l OTHER; AP.PROX,BORING DEPTH' ,`l� t ❑BOLTED TRAFFIC BOX OR --'STOVEPIPE <br /> / CONDUCTOR CASING PROP SED (if YE ,IEst s ecitcations In cummentseciion) <br /> COMMENTS:� 10 eo sob i ri a A u ell W�, rz :6 r c, eas <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 I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations, II applic le Calif rnia Laws. <br /> Signed Title/Company <br /> ` 1 �i VIfl3�i trL .J1�rCfi�.If�C, I <br /> Print Name b�1 n L l}Ch Dato �I I ' Z008 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 2 Cl6 3 3 v� <br /> WORK PLAN DATED: . V 2 I t 0 -T <br /> APPLICATION ACCEPTED BY DATE ISSUED d AREA <br /> GROUT INSPECTION BY "APIC- FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS; <br /> ACCOUNTING ONLY: AID# ��.00 bpi rs FAC# <br /> DATE PE3S SSS <br /> ICE <br /> q <br /> MIT,REMITTED (CHECKilECV'D-13Y <br /> OPE CODES FEE INAMT <br /> 35-0 I R <br /> C-57 <br /> WC _ -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 14!5107(WEB) WELL PERMIT APP <br />