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oP°`''" San Joaquin County <br /> Env .,,nmental Health Department - SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www. gov.org/er I� ;';I_ <br /> sjhd ;- KNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDDf r 3 F'�� 7' �� <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 Environmental Health Department. <br /> �S' �a// i,//� W t� Assessors <br /> WELL Location Ph !/!/O Cross Street WGS� oK Cit Zip 5a3 Parcel ors —01 <br /> PROPERy , <br /> Owne 1 GK 9 r PsI. Address_9a-1. lVIke,17City-0"*Zip ?,tULPhone#d?Up— /n <br /> C-57 Contractor_2z,L I Address 1SC Cit Zi Lic# Phone#S %?,3;Z-:W <br /> s <br /> Consultant/Sub Cntr�GttiTC(n WT— Address 106:a UkkRoCkpd City (h( u # Vfir Phone#WS53•y0 <br /> l+G100 <br /> GIS Coordinates:X Y Township 15 Range 64 Section 491 9 I(� <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING n,GE OBE,HYDROPUNC HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# c�:nQ. ,pio <br /> W7 0 PRESSURE GROUT <br /> *Other i f GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA: /4_ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS /2l TYPE OF CASING: O STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL A65Ct,49-C— TREMIE TYPE TO BE USED: O AUGERS 0 HOSE <br /> O AIR SPARGE/OZONEtg.2USH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes wo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> [ SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS�T1�Tr G .tel <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH © O BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTO CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: /b R L < ?V-,6-- ktA <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROA <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. 1 i <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, R sadeg tions, and all applicable California State Laws. <br /> Signed x Title/Company <br /> Print Name_ Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: C1 2-51 • 1,)o ( rc r2,,k I'eVy"i/J. <br /> WORK PLAN DATED: z 2-- <br /> Application Accepted By ne- Date Issued I I Z��D`( Area L! <br /> Grout Inspection By U ��. Date L D Final Inspection By \N tncti. Date t6 40 <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: 1— <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# iQV91 E <br /> a`to I A i6j.00 1-TO5 V I SR# 4 o-4-ci Z <br /> ---� C(� <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit Encroachment d <br /> 6 <br /> EHD 29-02-001 <br /> 6/22/04 <br />