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I � <br /> >oPgUIN. c San Joaquin County <br /> Environmental Health Department SITE <br /> N: 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 /> q<fFc) 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 Environ <br /> ��ental Health epartm[ennt 5S- (0-16/`�7 /' <br /> /SL_ OP ��—O� l�rC-1 �' y LWIAU P ,:�S Assessors ✓ — (0-1 3 <br /> WELL Location _Cross Street Cit Zi Parcel# J <br /> PROP��((��TY �I 0 <br /> PROP &)IAr;L aOC21/[j Address ��70�—.y6yj!�>�pw' /V�✓ cityV 'Ut Zip�fpJ3()-7phone# <br /> C-67 Contractor s Wff(taC Address 1 J " 4Qu,,%,h+'�G�F{i�Y},.� City (+��/p��ttd'.. ip l�Lic��/y. Phone#p/ .�j�p ? <br /> Consultant/Sub Cnntr .�3 Y7/C ppAddress 3ho wrvT P(1 CiNy f/k'M/ / VZZPhone# A -_p/ ! / —J7�� <br /> GIS Coordinates:X39 37 I Y U1 p I ! I O rW,Township . _Range k1 � Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL BGBORIN#G pT AO B� FAY ROPUNCt HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> +D / OVER-BORE. DIAMETER <br /> WELL# 0 PRESSURE GROUT <br /> 0.Other / GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 0� <br /> XMONITORING HOLLOW STEM DIA.OF BOREHOL — " F MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> o EXTRACTION o AIR HAMMER/DRIVEN CASING THICKNESSS`ff 40 TYPE OF CASING: D STEEL )<(IVC ()OTHER: <br /> []VAPOR B MUD ROTARY DEPTH OF GROUT SEAL O_- / TREMIE TYPE TO BE USED: VUGERS X-IOSE <br /> p AIR SPARGE/OZONE XPUSH POINT(GP or CPT)GROUT SEAL PUMPED: B Yap a NoNOTE: AXIM FREE-FALL DEPTH IS 30') <br /> SOIL BORING t)HAND AUGER GROUT SPECIFICATIONS C/Yi� <br /> p OTHER: a OTHER APPROX.BORING DEPTH U BOLTED TRAFFIC BOX or p STOVE PIPE <br /> j�� ,,� CONDUCTOR CASING PROPOSE (if YES,list specificati/omens,in�comment section) <br /> / Y C' <br /> COMMENTS: J-JIfICI S N?t f 'ffz pyett tCR P2 —7Ol 1 � <br /> ��� LLI-s l � hl <br /> p� XI ✓!`7/CCS/ �-� <br /> tD�P (VO-37 M 0_ P i Ei'� Tv/e 'f' rYYi 6*t'�CjI57_719 7077q'G- 'i Tpy• <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, R and R ulatiloons, and all applicable California State Laws. / <br /> Signed x� "" "�t//1 Title/Company W �r lTtirs C/%Z—A <br /> Print Name to Tl J r'a't C Z Date Rot- a5�'/�.(S"�c71 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued 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 TCHECK# 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 /> BHD 29-02-001 <br /> 6/22/04 <br />