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I � <br /> San Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> i <br /> " •' : (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> c= <br /> 9�/l-oRN�P <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�TTiitle,,Chapter 9-1115.3 and the Standards of San Joaquin County�Ennvi�ronnmrental)Health Department. � <br /> 36_"W wem et)l Yt 6�/ 33 VI pPWAt Il S3 g9P-, essor�5s ��._�"3 <br /> WELL Location{{�� + y��f V ////_�/CrossStreet City � Zip Parcel#W <br /> OwOerE 'F J/. 8 CLCI 1V I Address C00 (A/.�C�(ZY � CityjQC L ��3�'� <br /> /�,, / {Y Zip C Phone©# / h �7t� ` �Q C <br /> C-57 Contractor�•�KA:�i'���,,rrb1 fyy/j Li IPIL± Address -0 YOU �1. �i-City !�P ip Lig/�0��/b�hone�j# n(.�-�/�$�"Jr9 �`j <br /> Consultant/Sub Cnir i)1TI l.� Address50©O yVrI1C FY4et Cily � Qidt /Ugj Phone#1115 <br /> 37°3"1 `46�`fLtk UI 10"W, p� _ g 6E7Section— <br /> WORK <br /> 5 � <br /> GIS Coordinates:X < Townshi Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/ BORING PT GEOP O YDROPUNCH AND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> ` OIL BORING# 5 11 5'g 3 �' OVER-BORE. DIAMETER <br /> p WELL# p PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: NW5-5- ig�_ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS n <br /> 0 MONITORING HOLLOW STEM DIA.OF BOREHOLE - 'r a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA:fC <br /> o EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: p STEEL a PVC a OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 0—TD TREMIE TYPE TO BE USED: kAUGERS JkHOSE <br /> p AIR SPARGE/OZONE XPUSH POINT(GP or CPT)GROUT SEAL PUMPED: Vies p,a�N,oG%i(NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> AlSOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 9t' r'ym <br /> l.OTHER: p OTHER APPROX.BORING DEPTH 10 FE. a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> //�(� // /� / ��! C-yO�N�D�UCyTyO�R CASING P/RO�POSED (if YES,list specifications in comment>section) <br /> COMMENTS: 1/VC-S bJl Zl � c �r f`"'b'"/ IBJ/ /71 SKIP, 4516" 70 7-07&C- 0�i%t7`7 <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 prepayep this application and that the work will be done in accordance with San Joaquin <br /> County Ordinan es, R I and a ulations,and all applicable California State Laws. <br /> ��y ppp``` .n �_� <br /> Signed x / /'1 LL Title/Company p-�i�SCI /�f�)r�% � C- <br /> Print Name C Y " C Date �1r ,6LFl <br /> t <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 <br /> ateDestruction 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 /> SR# <br /> i <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />