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San Joaquin County <br /> a� Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> ., <br /> V.. (209)468-3449 Fax: (209)468-3433 Web: wNvw.sjgov.org/ehd UNIT IV <br /> 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,C pter 9-111 3 and the Standards of San Joaquin County Environmental Health Department. <br /> a .z LI-7 <r � Assessors <br /> WELL Locatior� Cross Street VCity Zip Parcel# 0'23-ft -03 <br /> PROPERTY ApeduL S I _// /rI Q2 <br /> Owner ` S EYI '�Yl b�E Address 2247 E Pjrt��It `City �G�t Zip�2`1DPhon)e(# 26q �p ,} 064'2 <br /> C-57 Contractor�aT�r,l�* Q 4Address 88,3 C/rGinnnf y Ro�KI;^ Zi ���� ""!K <br /> n A!Cit p 9 Lic# one# <br /> — <br /> Consultant/Sub Cntr Address City Lic# Phone# <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> )kNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> ,)o SOIL BORING# _ OVER-BORE. DIAMETER <br /> WELL# 2 Di�2o�, Q .o_rs C (�� W� PRESSURE GROUT <br /> a*Other ROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SP CIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE D MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL XVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: O AUGERS 0 HOSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes U No (NOTE- FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER: a OTHER APPROX.BORING DEPTH 3D'- �� 0 BOLTED TRAFFIC BOX or O 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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x `C Title/Company � L/ TC SS Gi i(�P �C qY <br /> Print Name��J�(r �--�J�h Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: m (� <br /> WORK PLAN DATED: <br /> IVP- <br /> Application Accepted By Date Issued -7 Area <br /> Grout Inspection By (� ;�; r lvc� ate I 1`1 f C'5� 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 /> SR# 'f3C <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 />