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P�•u'k •San Joaquin County � I <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor,Stockton,CA 95202 MITIGATION <br /> r; n(209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> Cq</FOR�`P Well Permit Application <br /> 1 <br /> WON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED 011-1pt)'17 r t I r <br /> Application is here 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 /> ' Assessors <br /> WELL Location lr?o p..�6 - _ '^"�_Cross Street City Zip 3J Parcel# <br /> PROPERTY� / �y / �/ �� <br /> Owner E [7T- /�'f'Address /�1�2/rd City«7' Zipp,S�3}!� Phone# O <br /> C•57 Contractor R,6,9Wi/�-z�-�/I !/ Address�r)1gOX �J 6t-� CiltX`lL�=� Ziptl —I �J.S��'r/.3� <br /> Consultant/Sub Cnlr�kzz--I el?( - Address.�1E s 'yWZF-City�Lic# Phone# �fJ -13 <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> D NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> a SOIL BORING# O OVER-BORE. DIAMETER <br /> "$•WELL# Yf� �-�� a PRESSURE GROUT <br /> 0 Other GROUT SPECIFICATIONS <br /> COMMENTS: — <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS !!-�-,i <br /> �AONITORING HOLLOW STEM DIA.OF BOREHOLE o MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA:T___ <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS, yb TYPE OF CASING: a STEEL PVC 0 OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: XAUGERS a HOSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: II Yes No NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING u HAND AUGER GROUT SPECIFICATIONS C <br /> 0 OTHER: p OTHER APPROX.BORING DEPTH_ ,>-7 ��OLTED TRAFFIC BOX STOVE PIPE Zr <br /> CONDUCTOR CASING PROPOSED (if YES,�st specifications In comment section) <br /> COMMENTS: <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 x Title/Company(- <br /> Print Name c�l" �LC � DateLl�/O <br /> DEpPARTMEh T USE N X <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED:_ �- �Q C <br /> Application Accepted By Dale Issued y( -0 / Area <br /> Grout Inspection By Date Final Inspeclior� A 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 I SERVICE REQUEST# INVOICE <br /> SR# ©� <br /> C-57_ WC_WAIVER_ r C-57 Letter of Authorization to sign per Encroachment doc_ <br /> EHD 29-02-001 - <br /> 6/22/04 <br />