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,T <br /> San Joaquin County <br /> Environmental Health Department SITE <br /> 600 E. Main Street,Stockton,CA 95202-3029 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/chd <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 Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> CAST SIDE:-F HWY 33, i-Asr I c1 Assessors <br /> WELL Location OE IF, IC,AIIDN CANAL- w <br /> Cross Street ELTY Ro&,Ver eryioL $ Zip9�30 T Parcel# 2-55x" IGO -16 <br /> 13o91NG gE'ST AeCE55ev VIA WEI-Ty ROAD <br /> PROPERTY <br /> Owner MICHAEL-$ L• So&E�Address P C'. L?OX 2 (y <br /> .3 CittyVery)aI S Zip7.5,384hone# NA <br /> C-57 Contractor RS1 DRIe.4-1 NG Address 2 S7-20• N- EASE City-WooDca g5�7Ciic#8 233 hone# �� 61-F 2-'12-11 <br /> Consultant/Sub Cntr 5A I C. Address 3800 ( )ixff-Atle�Sfe ZCitty SAC AAW44 NA Phone#016)q16-3075 CC// <br /> GIS Coordinates:X _ IZI • zS�9 Y 37.630? Township 35 ort Range f0 ���� Section 63g'7�D55 <br /> WORK TO BE PERFORMED: <br /> INEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> -JAOILBORING# S8-2-(0 a OVER-BORE. DIAMETER <br /> a WELL# Q PRESSURE GROUT <br /> Q-Oth GROUT SPECIFICATIONS <br /> COMMENTS: S.3-Co• '.bo /�i�iSbh'D <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING (I HOLLOW STEM DIA.OF BOREHOLE2-3,f a MULTIPLE CASINGS Q MULTt-LEVEL WELL CASING DIA: ISA <br /> a EXTRACTION u AIR HAMMER/DRIVEN CASING THICKNESS N A TYPE OF CASING: Q STEEL a PVC Q OTHER: NA <br /> I]VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL �f D _TREMIE TYPE TO BE USED: I]AUGERS X"%E-•]W f E <br /> p AIR SPARGE/OZONE XPUSH POINT(GP or CPT)GROUT SEAL PUMPED: U Yes p No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS. NEAT CEMCPJ7 — <br /> I]OTHER: []OTHER APPROX.BORING DEPTH Yn n BOLTED TRAFFIC BOX or a 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 I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County onrdices,Rul Reg tions,and all applicable California State Laws. <br /> Signed /r�'/ A� �^ /,' /� Tide/Company e C7 �O pG/eY1�Is7 <br /> Print Name_ VrllLLlA JLO " Ll Date O _ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE D <br /> WORK PLAN DATED: O7 purs l( G✓)eI 0C� c <br /> Application Accepted d " Date Issued % Areal 7 <br /> Grout Inspection By Dat Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: U) e Al-UST Zte Mtf 1 J, WIL k- 0--Z <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 0 01 5�- r�9- c .�. !. .3 0� SR# Ov SD <br /> C-57_ Wi-WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc_ <br /> EHD 29-02-001 web <br /> 6/22/04 <br />