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a C) <br /> San Joaquin Count <br /> �fl�6 Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor, Stockt n, CA 95202 MITIGATION <br /> EP,LT,1(209) 468-3449 Fax: (209)468-3433 Web:w w.sjgov.org/ehd UNIT IV <br /> p�nf ., _� 4f 4C5 Well Permit Applicati n <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FRC M DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install th 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 /> Assessors <br /> WELL Location M 3t trE� e Cross Street - tm'� City C `�+i� zipc� c.) Parcel# (L� 00 <br /> PROPERTY1 <br /> �- u Address � <br /> Owner �n �- 1 s ': �l�J �. Zip�1� Phone# <br /> C-57 Contractor I1Se9-.PJ¢-4WA)y Address 3��.Shegts AA24!c Cit k dip 3�Lic#�S� �L�Phone#2ag177a 35�U <br /> Consultant!Sub Cntr�,f�t ilr rbf��c' r��. �y�Address �� . I �;C 4±52,— City O ifr� Lic# Phone# xS > " ��G 5 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,O HER-) p DESTRUCTION (choose type below) <br /> *SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0"Other GROUT SPECIFICATIONS <br /> COMMENTS -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA-OF BOREHOLE 2 r` 0 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 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE!OZONE APUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS C---' � <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or Q 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 thework will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed g Tltlefcomp ny {]'.�3 # Lv ! •c c �T <br /> Print Na Date_ -- <br /> DEPARTMENT USE7 ONLY L <br /> SITE MAP IN UNIT IV FILE, ADDRESS: a q t + <br /> WORK PLAN DATED: I D <br /> Application Accepted By _ D to Issued p� b Area <br /> Grout inspection By ate 7- 'Z4s Final 1 spection By t- "� G '^- Date �- <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> ;Lq SR# °t� <br /> C-57 WCC WATVE€2� C-57 Letter of Authorization to ign permit Encroachment doc <br /> EMD 29-02-0.01 <br /> 6122/04 <br />