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�,Qu,ry --San Joaquin County <br /> Envi>t,%-qimental Health Department SITE <br /> 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 /> Q <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 Environmental Health Department. <br /> c� j i y'� Assessors <br /> WELL Location �y 7 Sc S� �� Cross Street�kS�City Zip © Parcel# <br /> PROPZ&V) �-6124 G)J zip <br /> ? `–t X —I'FZ <br /> OwneRT� l { ���i �/ (1(–Address Cit Zip Phone# <br /> C-57 Contractor C 7 Address G>:S sl -eL40 /`�` CityS CJt Zip � ic# 7Phone# 1 <br /> Consultant/Sub Cntr Address City Lic# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING I;PT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# [;1S 1]OVER-BORE. DIAMETER <br /> D ELL# 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: r r r, + q ^,� f, •. -q «,,. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE(]MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 157�5 ig'�fi"TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE ePUSH POINT( P r CPT)GROUT SEAL PUMPED: 0 Yes /E(No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_G OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 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 1 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 L ws. <br /> .- <br /> Signed x Title/Company <br /> Print Name V"� � '-(. � U Date l � r <br /> DEPARTMENT USE ONLY t <br /> SITE MAP IN UNIT IV FILE, ADDRESS: I b 1 Sc4,00S <br /> WORK PLAN DATED: -(!Z8 1515— <br /> Application <br /> orApplication Accepted BDate Issued 1 I I-A j o& Area Z I <br /> Grout Inspection By (.lA��.G1n.� Date 2 Final Inspection By (A r�� Date v O <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# F <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3"I .ccs Z3�{1Z- 6� 112-/oG SR# 5� Pbq <br /> L .od <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 />