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a�U'N San Joaquin County <br /> iz Environmental Health Department SITE <br /> IrN' �� 1 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209) 468-3449 Fax: (209) 468-3433 Web: www.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,Chapter 9-1115.3 and the Standards of San Joaquin County <br /> (�nx Y1fi L� Environmental Health Department. <br /> 01UA <br /> ssessors <br /> ' a�G <br /> "�S ' 0WELL Location Cross Street city Zip Parcel# <br /> PROPERTY tom,, <br /> Owner 5��(�(� I�l)�` k!k ' Address 258C) ISVQd�D1 14,C CityL.tVC0n0(-C Zipq1I55 ( Phone#9Z`7 2�{' -31Dq(v <br /> C-57 Contractor?Y6,%NM,5'Ly pt%M _Address ►U$1 ' <br /> �SS�X rj\e City 1 r1 ` U `I <br /> pLl �I Li #kc ��Phone# 23J-`-f5 �5 <br /> Consultant/Sub Cntr e-,rro,-&ea rCJA 61(, Address `Jl t06 LizS Zy 3 -L�LZ <br /> T 2�1'�,UrCS,n,/QCity � �`(Lic# Phone# <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROB HYDROPUNCH, HAND-AUGER,OTHER') []DESTRUCTION (choose type below) <br /> SOIL BORING#.c�d ° []OVER-BORE. DIAMETER <br /> []WELL# []PRESSURE GROUT <br /> []*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> []MONITORING HOLLOW STEM DIA.OF BOREHOLE []MULTIPLE CASINGS []MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: []STEEL o PVC Q OTHER: <br /> []VAPOR []MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: []AUGERS []HOSE <br /> (1 AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: []Yes []No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING []HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER:_0 OTHER APPROX.BORING DEPTH []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 O1rdinrapc�eq,,,tulles and Regulations, and all applicable California State Laws. <br /> Signed x ,� V/�I.VL(�VL ��Lti Title/Company <br /> Print Name �� ���r'` EVn�S Date 012- (1 0 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date 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 I SERVICE REQUEST# INVOICE <br /> SR# <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 />