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L J <br />�_I <br />San Joaquin County <br />Environmental Health Department <br />600 E. Main Street, Stockton, CA 95202-3029 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Well Permit Application <br />SITE <br />MITIGATION <br />UNIT IV <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 />Assessors Z <br />WELL Location ?>24 Z Ebr"AA 5't ed' Cross Street V � ACity S_MGY4 �{ Zip 9S2y� Parcel# 1-77 OW2-q <br />PROPE1jTY ` ,�,,,,j,,,� I 2�l( (� U� i1� Gl�P a" <br />Owner ( OV'P [A&WZ N' /C -Address j 11iy�t�, t/IL- City V & Zip honUe# r`-�,'� -/��j iGtYyr y`i <br />C-57 Contractor � rte, l{� AddressgSC) ty'� City�Zip� � Lic# I %S Phone �l�^-� 3^ ✓%oo <br />Consultant/ Sub Cntr t y «Til' 1lt►� C'flVt. Address eA1,14 WAG 11 �e0S' 44i Lic# 3_b Phone# �l'4-�r�S <br />t '/'- �� <br />GIS Coordinates: X_IU'y1" �• Sb t , Y 3 "U rj 0•Di�t , Township Range v Section <br />WORK TO BE PERFORMED: <br />J�f4EW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />0 WELL # 0 PRESSURE GROUT <br />"Other 0. (per_ ?� GROUT SPECIFICATIONS <br />COMMENTS: -- <br />t <br />o -7S - <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONStt <br />' <br />0 MONITORING ) IOLLOW STEM DIA. OF BOREHOLE ,MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING q,A: <br />0 EXTRACTION 0\AIR HAMMER/DRIVEN CASING THICKNESS _PE OF CASING: 0 STEEL XPVC 0 OTHER: <br />,KVAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL�TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes ^OTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS ✓1 ik <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH S 0 BOLTED TRAFFIC BOX or XSTOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: 9 <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinances R . les and Regulations, and all applicable California State Laws. <br />Signed x ,n �y a Title/Company �IP� ►/%Q-� `-44 <br />Print Name 't t ► }�/ Date 7 4�t <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: PAYMENT <br />WORK PLAN DATED: RE <br />CEIVLU <br />Application Accepted By �y�� �" - Date Issued az 007Area <br />Grout Inspection By -r Date9 B Final Inspection By v pate 9 <br />Destruction Inspection By Date SAN JOAQUIN COU <br />COMMENTS / CONDITIONS: WPM TH DEPARTMENT <br />ACCOUNTING ONLY: AID# FAC# 1 11 <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK It <br />RECC''D BY <br />DATE PERMIT / SERVICE REQUEST ## <br />INVOICE <br />SR#(j(�rrl�%!S <br />C-57_ WC Y -WAIVER C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br />EHD 29-02-001web <br />6/22/04 <br />