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0 • <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 />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />SITE <br />MITIGATION <br />UNIT IV <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 Zp� <br />WELL Location 3z4 Z s. l:: ik�f"d b Street Cross Street V P1L"e City S"�1�vt Zip `1sZv� Parcel# i? 7 OW <br />2—q <br />TY �,,,�j,,,� � t� ��/ /�,3�,,r�U�/sS�_Y/JMFAi�A� <br />Owner ( DVP (A&fVXjt6jAddress 2aY !1,kLyy D& City S �/ Zip'1JGVPhone# l��'/'� /�� 3y��( IG�Y+► �'� <br />C-57 Contractorel r —'4"�ql �4 Addressgsd tbLy eeto cityZip'14W Lic# �S S Phone q2- � —3-5%00 <br />Consultant / Sub Cntr it tttr 600YS evI . Address I14 i1 A �e.&44L-bity Lic# -W6 Phone# -7I'4-6 —6'C' / <br />GIS Coordinates: X-174 yz' LV GO , Y 31 SO' UI Township Range Section <br />WORK TO BE PERFORMED: <br />JK4EW WELL / BORING <br />0 SOIL BORING # _ <br />n WELL # <br />(CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS !1 <br />0 MONITORING IOLLOW STEM DIA. OF BOREHOLE ,MULTIPLE CASINGS a MULTI-LEVEL WELL CASING IjIA: <br />0 EXTRACTION �a AIR HAMMER/DRIVEN CASING THICKNESS PE OF CASING: a STEEL XPVC a OTHER: <br />,)�/APOR 0 MUD ROTARY DEPTH OF GROUT SEAL Set BSWP 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: MAX�I`M^UM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS �� .1(I - S V� <br />- W' I'� <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH S 0 BOLTED TRAFFIC BOX or ASTOVE PIPE <br />fib?- CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: S <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, R,1 and Regulations, and all applicable California State Laws. _ <br />Signed x � �/ TitlelCompany. Ili��_�� <br />Print <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted <br />Grout Inspection By_ <br />DEPARTMENT USE ONLY <br />7—M, . <br />PAYMENT <br />RECEIVED <br />1411- WAF-0 Date Issued % 1'3 Area <br />9 7O Final Inspection By ii/ Ali ENr�7 <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />8 . `f' <br />l � `f <br />2r� <br />�� I `pfd7 <br />SR# ©o 5135 <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br />EHD 29-02-001web <br />6/22/04 <br />