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y-� <br /> op . kl „c '10anJoaquin'Countx <br /> Environmental Health Department - -�F y <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 R kl" MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> Well Permit Application NOV' 2 4 20(i4 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENpV��1Rp0pqN��ITTJii I,,' I'lcl <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applic2tloh'IS�MddV!nR� ''mpliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. 6 6 1 00V <br /> 1 ` c� `t�� .n� -Assessor '�� <br /> WELL Location 16104 k.tea c 1 M CNv \moo•cross Street r+ti N City l�,Zip Parcel#, 9 l — 7 I <br /> PROP RTY fir, ` 11 1 �ToZ.3330 <br /> owner 05¢1Mx1 T �t-t^�-Address 7 Z.2.��O�w.ecl4L�'d'�� City .0 _Zip Phone# �� 7 0 - <br /> C-57 Contractor t ��'tUc l Address SOU dt CilyT0; , Zip Lic# Phon/e# 7�) '4"'41 O U <br /> Consultant/Sub Cntr lJ"Gr O Address{.3I Cor,+.w,r &400 Cityj(DC�,Lic# �PhonetK9� 7$"6 BZ <br /> GIS Coordinates:X _ ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ANEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> a SOIL BORING#_ 0 OVER-BORE. DIAMETER <br /> ,WELL# Mtn1—XJ - 0PRESSURE GROUT <br /> 0 Other GROUT SPECIFICATIONS <br /> COMMENTS: — <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING )WOLLOW STEM-. DIA.OF BOREHOLE 0 MULTIPLE CASINGS a MULTI-LEVELL/�D,VELL CASING DIA: _ <br /> a EXTRACTION o AIR HAMMERIDRIVEN CASING THICKNESSSJ..a 40 TYPE OF CASING: a STEEL 1prVC 0 OTHER: <br /> D VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE US(E� 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes ,fNq ( OTE: MAtXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS X)tA—;k <br /> 0 OTHER:_ 0 OTHER APPROX.BORING DEPTH —7 SJ 0 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 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 rdinances a and R aEia d-all-applicable CaliforniaaSStattee(}Lka/�w�.s. _ r <br /> Title/Company s - V �-+ Wl9t�/ JjG— <br /> Signed x �^` , ` (,r <br /> Print Nam qr_r_ 1 - of Dale Z�^,y�V 1 <br /> DEPARTMENT USE ONLY �� J <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 041 Uwman A""""`r t`-a'r — <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued �z-z­0 C/ Area 01W <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFOj AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> " SR# 0��! <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign perrnit�EnctwkE"Mnt doc_ <br /> EHD 29-02-001 ,^'G <br /> 6/22/04 <br />