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Apr 28 05 11 : 30a , <br /> P.5 <br /> aav r San Joaquin County <br /> N % Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 MITIGATION <br /> x (209)468-3449 Fax:(209)468.3433 Web: wwwsjgov.org/ehd UNIT IV <br /> c``'F°"• P 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 andlor install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-11115,.33 and the Standards of San Joaquin County Egn-viirro/tnTental Health aparttmeennttn <br /> WELL Location /`r g Ju l S C)f C%y Cross Street I_ Je� y '�'/C./ Ajl ZI c gr Y ssesso <br /> Cil Parcel# <br /> PROP�F{TY �'i�� <br /> OwnerMl .}f[}�_F6�_,_(,J�1(] ) f Address 7 �p�©- p/ �q(X! (%�✓� CITYIMAf0—ZZI M/L�JU�Phone# <br /> C-57 Contmctor6 rj•9 fx(�ILnI,W C Address I S� QN/hd�N�/�c,'Fc'LAY,�r-COMEa�rcCZlp 17 LIcfl Phone,# ! .f�-7 <br /> Consultant/Sub C2ntrp� .�I tTI� J� 1Address <br /> OwT✓J/rIY(Y Oity�lhF// t #_/�n// <br /> XJ l I b(,�0I I t J rW,Township _Range 0 � Section �l cJr <br /> GIS Coordinates: / Y Q <br /> WORK TO BE PERFORMED: <br /> [I NEW WEOLB RILL[BORIy#G l( T,GOP BY ROPUNC HAND-AUGER,OTHER-) DDESTRUCTION (choose type below) ' <br /> C OVER-BORE. DIAM <br /> Pg'�"'r."$,YELL#. /VI d51_ __� �� � OPRESSURE GROUT ETER <br /> COMMENTS:O'O- / GROUT SPECIFICATIONS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS // <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE - °j n MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION n AIR HAMMER/DRIVEN CASING THICKNESS0 TYPE OF CASING: D STEEL xl�'VC n OTHER: <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL O-- TREMIE TYPE TO BE USED: VUGERS I OSE <br /> D AIR SPARGE/OZONE XPUSH POINT(GP or CPT)GROUT SEAL PUMPED: DYs 0NoNOTE: AXIM FREE-FALL DEPTHIS 301) <br /> SOIL BORING aHAND AUGER GROUT SPECIFICATIONS <br /> D OTHER: D OTHER APPROX.BORING DEPTH �(� BOLTED TRAFFIC BOX or D STOVE PIPE <br /> 3t� /�q/1(�� CONDUCTOR CASING PROPOSE (if YES,list specifications in comment section <br /> COMMENTS: Xn.'!CI ! r V/ G"LIL[ lr9G J)�/t t 'T TJ TOl f L I�ZLCi l� TIT/ IE�F))CI LO*J )� <br /> PV� 1'V(j-� (�LL ✓o C7"�'�BGr T�� J�5•'f �r'L'Y�Fi9-C�T� TUTP�L d'3'�Tpt-/. <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 Ordinan es, Rand R ulatilo�ns,and all applicable California State Laws. <br /> Signed per"^ `7./I Title/Company C <br /> Print Name Date e/(- 'ej4 xrC 6 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted Dy Date Issued <br /> Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY; AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> S R# <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br /> EFID 29-02-001 <br /> 6/22/04 <br />