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oP D[ FILE COPY <br /> '&n Joaqum�County <br /> Environmental Healti:Department Sll"E <br /> N;] < 304 East Weber Avenue, 3rd Floor,Stockton, CA 95202 MITIGATION <br /> F• (209)468-3449 Fax:(209)468-3433 Web:www.sjgov.org/ehd I�iO� 2 k Z0 SNIT IV <br /> �,q,:+53a+t4ft:p <br /> <7F0a' Well Permit Application <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 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> /rye �/ 1 U k� � Assessors <br /> WELL Location �7�/ ��4-tc"L^-vJ'��� _Cross Street l rti^ City {L� � Zip Parcel#�RI'•Z �I <br /> PROPERTY 1 1 '�,,,Vcr^�-�0.bdress Z22G �^� City OSW✓�l Zip2S6tiI_Phone#C916 �-$Z 3330 <br /> Owner Il0$0.\1J��2 p <br /> ` ,rl 1 1 , UU $' JT• jj!_4t,- Zip Lic#Zjg101 Phone#�I6 7-4 100 <br /> C-57 Contractor V W1Ty^M\'^� Address I Cit/ >� <br /> Consultant/Sub Cntr <br /> r"-'n.nr F-U Address�j3� OU�L^'1yctiWity� ,Lte Lic# N <br /> GIS Coordinates:X- <br /> y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> WNEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> II SOIL BOR JGIf UOVER-BORE. DIAMETER <br /> aPRESSURE GROUT <br /> µ u GROUT SPECIFI TIONS <br /> []'Other <br /> COMMENTS: ? --- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING >4iOLLOW STEM DIA.OF BOREHOLE r u MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA <br /> []EXTRACTION aAIR HAMMER/DRIVEN CASING THICKNESS LIFO <br /> S TYPE OF CASING: U STEEL APVC []OTHER: <br /> [j VAPOR o MUD ROTARY DEPTH OF GROUT SEAL, 1�TREMIE TYPE TO BE USED: ()AUGERS a HOSE <br /> []AIR SPARGE/OZONE U PUSH POINT(GP or GPT)GROUT SEAL PUMPED: ]]Yes ;JJN6 NOTE: AXIMUM FREE-FALL DEPTH IS 30') <br /> []SOIL BORING aHAND AUGER GROUT SPECIFICATIONS- N Q� �R- <br /> []OTHER: 0 OTHER APPROX.BORING DEPT6 ? [I BOLTED TRAFFIC BOX or STOVE PIPE <br /> .CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED F R INSPECTIONS. <br /> I hereby certify that I have prepare&this application and that the work will be done in accordance with San Joaquin <br /> County Ordinance a nd Re and all applicable California State Laws. / <br /> 5' � <br /> Title/Company G St <br /> Signed x_ ( _ 1 Z Z.-.'v,� ti ^:� , t ( Q-t�- Date o V <br /> Print Nam <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: l� <br /> WORK PLAN DATED: I <br /> Date Issued � Area <br /> Application Accepted By Date <br /> Grout Inspection By_ Date Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT SERVICE REQUEST# INVOICE <br /> sR# D <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_. ment doc_6 <br /> EHD29-02-001 FILE COPY <br /> 6/22104 <br />