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FILE COPY <br /> San Joaquin County �� r� !Environmental Health De artmen`t EP l U <br /> P SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95r2 7 5 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/eM ZC�� UNIT IV <br /> Well Permit Application ";'r'a't' ' W �yE fiLI <br /> P ERri I��Sr ;� C'ES <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 <br /> (J9--111 .3 and the Standards ofSanJoaquin County Environmental Health Department. <br /> Locationo(�// —9C)1 "I (r`�l IS40 Cros Street 0Y- Cit � Zi ?520 Assessors 11-7- <br /> WELL <br /> Y p Parcel# <br /> PROP <br /> Owner ER r' ��U�`�` Address �y �`C�7 Cit yS a'k ip'fj20l Phone# <br /> C-57 ContractXzodrL t/n� V �t� Addresses 32 0l1 eG )�yv City )Ze ��,,rr��Zii��,, �ic#7/75?0Phone# q16 4.7s-(1 1116 / <br /> Consultant/Sub Cntr 1�C!�r Address tSYl4,j �City�eecyuic# Phone# tv 7 l <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 'kNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING,# 0 OVER-BORE. DIAMETER <br /> 0 WELL# 6 /— /7�G,�t� 0 PRESSURE GROUT <br /> I 0*Other ��"' GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIf ICA IONS <br /> MONITORING 141OLLOW STEM DIA.OF BOREHOLE_&!f ULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 2 L� <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL jf1PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL - � <br /> TREMIE TYPE TO BE USED: , UGERS a HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 N�o1(NOT�,: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 10ca/C�F-1 <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> , <br /> CONDUCTOR CASING PROPO E f YES,list specifications in comment section) <br /> AA , <br /> COMMENTS: A 1/ ya-'� L <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��nl,dn�Regulations,and all applicable California State Laws. /� `/ <br /> Signed x_u/(X,u�L2111 ) kjy�_ � Title/Company �6 Cf- C-4eb/ogL'ST"' <br /> Print Name �i(�� �/ �Ch.�� �� � Date(0—) <br /> DEPARTMENT USE ONLY ,r <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 2--2 l N— w l�R.10 <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued �� Area 6(e- <br /> Grout Inspection By t Date S 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 /> ?bio Ce 5 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 />