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�0 ' a 0San Joaquin County • <br /> z 2 Environmental Health Department <br /> m 600 E. Main Street, Stockton, CA 95202-3029 SITE <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd MITIGATION <br /> S�1FOR� 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 Title,Chlarpter 9-1115.3 and the Standards Ke <br /> San Joaquin County Environmental Health Department. <br /> WELL Location S e(J D 1.t)Cha d .kPA_Cross Street I(F N q F'6 c t`�Cit C' C. Assessors dd <br /> Y Cr�1U Zip SZLS-9 Parcel#(S <br /> PRO PER'�j n /� <br /> Owner 1'\�,t, T VII- . Address 12,0, 1Jn 1c (Z G 7 <br /> City. CQr�v-' G Z;p`I S 2SI Phone# ?-00l'- 3( l-Yg' -' <br /> C-57Contractor-) �,kt t4�r Address 36SGc> <br /> —I_ w aty57�c ten Zip S20�Lic#Si7-69 Phone# <br /> Consultant/Sytr Q -�1�+�,�ks Address62Z ici_soat St Gary S,. (= Lic# -- <br /> 7 Phone# ` 6--2'-/3^2.trO <br /> GIS Coordinates:X_12(=Zt{3 3 / ,Y 3 g, (�� ,Township I 1I N <br /> Section (5 <br /> WORK TO BE PERFORMED: Range—LTE­ <br /> Y,NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> r� p SOIL BORING# <br /> %WELL# N( W I -k 0 OVER-BORE. DIAMETER <br /> 'Other 0 PRESSURE GROUT <br /> f� >11 GROUT SPECIFICATIONS <br /> COMMENTS: 0 (/ �-`CP.,,,.� f�,,��,e <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING111 HOLLOW STEM DIA.OF BOREHOL <br /> 0 EXTRACTION � O MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIAZ'�iA. <br /> 0 AIR HAMMER/DRIVEN CASING THICKNESS S, qo <br /> 0 VAPOR TYPE OF CASING: 0 STEEL VC 0 OTHER: <br /> 0 MUD ROTARY DEPTH OF GROUT SEAL, -5 TREMIE TYPE TO BE USED: <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes 0 AUGERS HOSE <br /> 0 SOIL BORING /��e JJ 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> O HAND AUGER GROUT SPECIFICATIONS_/�'C!at 024, -�.X- <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 10 <br /> BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED IV() <br /> COMMENTS: (if YES,list specifications in comment section) <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 Ornes, Rules <br /> u e�d» Regulations, and all applicable California State LawsF�a . <br /> Signed x <br /> Ti <br /> -� `�r tle/Company <br /> Print Name � <br /> Date Q O <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADD ESS:� L�© (tJp '�j� ,� /�' rc�i1LQ� <br /> WORK PLAN DATED:qq � p 2©7 <br /> Application Accepted By. d t`vw'p�� ca g Q <br /> ��iiDate Issued_ r! -2-7�U7 Area <br /> Grout Inspection BY9LL-y Date �b / a7� <br /> Final Inspection By Date <br /> Destruction Inspection By DateT— <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PER <br /> SERVICE REQUEST# INVOICE <br /> /7--7 SR# 0055 l©l <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD 29-02-001 web <br /> 6/22/04 <br />