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San .Joaquin County <br /> Environmental Health Department SITE <br /> 600 E. Main Street,Stockton,CA 95202-3029 MITIGATION <br /> (209) 469-3449 Fax: (209)469-3433 Web:www.sjoov.org/clid UNIT IV <br /> c . <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 andler install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> EAST SIDE of HVJY 33, EAST pp / f c Assessors <br /> WELL Location_OEFP CAPON CANAL- CrossStreel WE -rl hoAqily Yt'rhQ-`I S Zip��3� 1 Parcel# 2.555" 2-GO -16 <br /> Bop4njG PP155T 6 4c C59E D VIA WELT)' ROA D <br /> PROPERTY y `1 1 Ci <br /> Owner M1eHAEL_$ '-, �O(sE�Address �. gOK �7l n3 Cityye{h0.lIS �Zci�plJ�3��Phone# N� !, <br /> C-57 Contractor RS/ J)91L[-1 A)C- Address z2D•N, FASB City w0OD(-A',rp g��7&ic#90233 hone# 5�)b1-g"ZYZ7 <br /> Consultant/Sub Cntr 58 101 Address 3800 WwftAve :5fr Z6ttySAc ARM 4it�! NA Phorie#0(6 /6-3075 -,f <br /> lz! 84`� 37.6302- Townshi �A (O �/�$� Section ' d38 7(055 <br /> GIS Coordinates:X � Y p 3 J�Du Range <br /> 35 <br /> WORK TO Rr-PERFORMED: <br /> NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH.HAND-AUGER,OTHER`) p DESTRUCTION (choose type below) <br /> ROIL BORING# S$-26 a OVER-BORE, DIAMETER <br /> WELL 11 PRESSURE GROUT <br /> j]'Othgi GROUT SPECIFICATIONS <br /> COMMENTS:7l� <br /> v <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 11 MONITORING I]HOLLOW STEM DIA.OF BOREHOLE2-3 v U MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: IVA <br /> U EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS t A TYPE OF CASING: Q STEEL I]PVC p OTHER: NA <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL`TREMIE TYPE TO BE USED: 11 AUGERS XH9GE-7RE1• C <br /> p AIR SPARGE!OZONE XPUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes p No (NOTE:MAXIMUM FREE-FALL DEP'T'H IS 30') <br /> SOIL BORING []HAND AUGER GROUT SPECIFICATIONS NCA?- CEMcl'l� <br /> ]]OTHER:__-----A OTHER APPROX.BORING DEPTH q10" 0 BOLTED TRAFFIC BOX or D 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 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi ces,Rul RecluAtions, and all applicable California State Laws. <br /> Signed x TitlelCompany I 11 G7 /OSpG(e1��15� <br /> Print Name INILLA 1�M SLOPIK\�( Date r/ O d <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE ADDRESS: j <br /> WORKPLAN DATED: /`/ O'• <br /> 1' iE,✓ -!' J Date issued Area 17 <br /> Application Accepted By <br /> Grout Inspection By Date Final Inspection By Date <br /> ' Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: L"0 J"'j'-! xv)f,� <br /> ACCOUNTING ONLY: AID# FAC# <br /> ' PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> C-57� WCC WAIVER_ C-57 Letter of Authorization to Sign permit_Encroachment doc <br /> EHD 29-02-001 web <br /> 6122/04 <br />