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San Joaquin County FILE COPY <br /> 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 /> A�IFORa`P Well Permit Application 1006 1 PM hi he <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED o*%DUN COUNTY <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work descri e whN�1MT*4Le in compliance with San <br /> Joaquin County Development Title,C+h,�apterr 9-1115.3��annd�thhe Standards of San Joaquin County Envirorni1jj7t5Pl5PArAnT'MENT <br /> �1 l v IJ� '""`t/C p (Sc��J Parcel#Assessors <br /> /7U2 <br /> WELL Location { toss Street Cit Zi <br /> 9� <br /> POwne ERT �he j' /�/_ � ress 1" <br /> C-57 Contractor 46 Address 93? S !c�J K oC CitUyjipf_'52��ic#45 none# '71ot>(O <br /> Consultant/Sub Cntr Address City Lic# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ,all <br /> �NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> SOIL BORING# a OVER-BORE. DIAMETER <br /> a WELL# 0 PRESSURE GROUT <br /> a*Other nn G�.R�.yO�UTT SPECIFICATIONS <br /> S <br /> COMMENTS: 5C5� , Q," /Flt/D7L <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE ^ MULTIPLE CASINGS Q MULTI LEVEL WELL CASING DIA:_IVA, <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL Q PVC a OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEALS TREMIE TYPE TO BE USED: D AUGERS Q HOSE <br /> a AIR SPARGE/OZONE/.ePUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING a HAND AUGER GROUT SPECIFICATIONS r7>C�2 a-�— <br /> a OTHER: a OTHER APPROX.BORING DEPTH e(�,S BOLTED TRAFFIC BOX or a STOVE PIPE <br /> 1 TCONDUCTASI PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: ~�P <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 a egulations,and all applicable California State Laws. _ <br /> Signed x �Y�L Title/Company �� !C>oi-17�q— <br /> Print Name �l + Date /J <br /> DEPARTMENT USE ONLY 2"'466 <br /> SITE MAP IN UNIT IV FILE, ESS: 02,19N. �4ul"6 <br /> WORK PLAN DATED: C� <br /> Application Accepted By Date Issued - , Area 6 <br /> Grout Inspection By Date Final Inspection By a` <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 /> �Z 7-11 SR# <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 />