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.pan Joa ui..n County FILE COPY <br /> 9 <br /> 1 Q o Environmental Health Department SITE <br /> 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 /> cA`';0Well Permit Application 2081AN 26I A " 47, <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> S,1, 6 A H —`J 'it:'u''J!°�T Y <br /> ''L1 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is ma&NN yt <br /> Joaquin County Development T'le,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Departmebll A f. r �1T <br /> 1 � ^ ,'1., a /� Assessors ©-.Z? <br /> WELL Location 1 y Cross StreetA Vl cd City Zip C Parcel#PROP /��7 �9 <br /> Owner ERTMI(ill1� 1 Address�U LU2� 0 L ( City S_(�Zi�52A Phone# 1`l�'Y '2—�4 ZZ Q <br /> C-57 Contractor 00 5�0�!/ee DJC � ' Address�ry 37 c�h�L 6,,),CityS�' Zip!547z Lic#7175/a Phone# V' 6 J� I b I <br /> Consultant/Sub Cntr A-6 0 Addressg�? 5 v�GCu City 4T Lic# Phone# ���� <br /> GIS Coordinates:X ,Y Township Range Section <br /> W RK TO BE PERFORMED: <br /> EW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> a SOIL BORT # OVER-BORE. DIAMETER <br /> a WELL# / I PRESSURE GROUT <br /> a*Other I GROUT SPECIFICATIONS <br /> COMMENTS: 1Ln C)oeAce 2�14 7.e.�L?. I S <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING 2,HOLLOW STEM DIA.OF BOREHOLE f 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA:��N�"1 <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL 10VC a OTHER: <br /> Q VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 7V �-�_ TREMIE TYPE TO BE USED: 0 AUGERS Q HOSE <br /> • j,AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 2''es a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> U SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER:_0 OTHER APPROX.BORING DEPTH e S �2+-R/BOLTED TRAFFIC BOX or O STOVE PIPE <br /> �^ CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: wle-1 (S <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 Ordinances, Rules and Regulations,and all applicable California State Laws. <br /> Signed x1,UcX t<�„� Gt J,e Title/Company <br /> Print Name b 2, Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ate" 9 /V• ll� U/a, , �✓ �"� <br /> WORK PLAN DATED: 1&4*j d4- <br /> Application Accepted By s4Date Issued l ZQ— d 4- Area 6�� <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 /> SR# � <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc V <br /> EHD 29-02-001 <br /> 6/22/04 <br />