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{} San Joaquin County <br />Z 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 �� <br />WELL Location 3zy Z S.L—I i�ctdD S-tY'eet Cross Street _City S'�DC��FYI Zip qS�?�%' Parcel# ?7 UW <br />tbA;�" Q��/ (310 Sys'—LI/ MC1417d'"r4ft <br />PROPE TY r %,� 2,��( �JL( D(L City SVG Zip-IJLYi 0hone# " 9Y� SL'WTirt�u4ti', <br />OwnerP� �S�'Address ��= <br />qSb tbv�e a Lic# y8!g6� q '� 3— 5 L <br />C-57 Contractor �r �! Address city Phone <br />' X14-5WI-S�%Sl—/ <br />Consultant / Sub Cntr 11I8r �� EV)Vt Address ;1124 Nlctan `�", �Zr kity Lic# -� Phone# 2 <br />GIS Coordinates: X-Iyt4s: Lig. Go" , Y5jk d 43-0'0(„ , Township Range C� Section <br />WORK TO BE PERFORMED: <br />.&4EW WELL / BORING <br />0 SOIL BORING # _ <br />a� WELL # <br />*Other <br />COMMENTS: <br />(CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />p DESTRUCTION (choose type below) <br />a OVER -BORE. DIAMETER <br />a PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS It <br />Q MONITORING 'HOLLOW STEM DIA. OF BOREHOLE ,MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING PIA: <br />EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS�� PE OF CASING STEEL PVC OTHER: <br />XAPOR a MUD ROTARY DEPTH OF GROUT SEAL <- 1' TREMIE TYPE TO BE USED: UGERS HOSE <br />p AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes : MAXIMUM J�,FREE-FALL DEPTH IS 30') <br />0 SOIL BORING HAND AUGER GROUT SPECIFICATIONS 4`Ir"e Gov <br />0 OTHER:_O OTHER APPROX. BORING DEPTH S BOLTED TRAFFIC BOX or ASTOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: tpC <br />NnTF- 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, Ran�Regulations, and all applicable California State Laws. <br />Signed x l'-� Title/Company "�it� � !S' ►f�U` lL► t <br />Print <br />Vl <br />—('K, -c <br />I DEPARTMENT USE ONLY PAYMENT <br />SITE MAP IN UNIT IV FILE, ADDRESS: RECEIVED <br />WORK PLAN DATED: <br />3 <br />j) Luvg <br />Application Accepted By a yd� Date Issued % ,- Area <br />Grout Inspection By �' Date Final In By ll+� <br />Destruction Inspection By Date l l Tw nGPARTMENT <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY I DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />'2,19 p <br />SR#� 3J <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 />