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o U.) • San Joaquin County 41 <br /> 2�- a`m 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 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. Th application is made in compliance with San <br /> Joaquin County Develogment Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental F ealth Department. <br /> ro/IACf / ,�iJt II�� A Assessors <br /> WELL Location Amcn��,,, M21ilrgO VI II j1I✓�rK Cross Street A� City Zip Parcel#1/7 '�'/)OJ <br /> // �� 1- x-ZW/ , i%sT �G <br /> 0,OFE /�� C.��CK / r 'ddress J��'1,N,cc�(-01,.-r City 4 L21no Zip ]Phone# <br /> C-57 Contractor Re6o�r,`Ax>/pu/ Z77/Address ZL✓ cCr City !W / Zip <br /> Consultant/Sub Cntr�J lj'} 67-6 Li Address�y�, City PC&4=Li Phone#_M7­7q3;-3 /0 <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING CPT,GEO ROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DEST UCTION (choose type below) <br /> `gSOIL BORING# - D O3 OOVER <br /> - ORE. DIAMETER <br /> WELL# 0 PRESE URE GROUT /� <br /> a`Other GROUT PECIFICATIONS�MIm 6!O✓J <br /> COMMENTS: f <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS A/^ <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE 7-// u MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA:'1 <br /> 0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS::�A TYPE OF CASIN : 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPETO BE USED: 0 AUGERS a HOSE <br /> a AIR SPARGE/OZONE $PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MA XIMUM FREE-FALL DEPTH IS 30') <br /> u SOIL BORING � a HAND AUGER GROUT SPECIFICATIONS )�� <br /> JtOTHER: a OTHER APPROX.BORING DEPTH _F+7 i Q BO TED TRAFFIC BOX or a STOVE PIPE <br /> ` 1 CONDUCTOR CASING PR POSED f YES,list specifications in comment section) <br /> COMMENTS: I TO ?6f I C Q !?I-OV7 4Q 17,04, <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 nces, Rut sand a and all applicable California State Laws1 <br /> Signed x /' Title/Company <br /> Print Name G/' Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: P <br /> Application Accepted By `/' ` • � Date Issued 'r/ 23 9 D 6 Area <br /> Grout Inspection By Date Final Inspection By Dale <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# I FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED C�HyECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 21c) 09 1 ��� S13fl SR#iii G <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorilro sign Permit_Er croachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />