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San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sigov.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 Stan ards of San Joaquin County Environmental Health Department, <br />WELL Location 0 t S C bry %�I� OfWC 3U�� 6/vc of Lyes►njr4 ygtiecr�/4. �I F00 b/ot-iAssessorsz� LZNos,tV �• /KINF�l <br />'7 �1Cross reef City 4ip Parcel# <br />PROPE TY /- r -' / <br />Owner _f { tl 01 S DC-�t t -AJ AddressS'¢Q-7 A/, E l &Irr IV City':Ax ! /y,✓ Zip 9,702 Phone# .2 d 93 7-634 <br />9 <br />C-57 Contractor gy IS t l- AddressISO SO 40CVe- "1A CityInu "2 ZipwLic#,�Phone# 11 �3 S800 <br />Consultant / Sub Cntr_;&2f etd t�'4Wy Address;3 % S%lGt tc: %d City C�c , Lic# CO 0?2 Phone# 146 %-/DDS, <br />GIS Coordinates: <br />WORK TO BE PERFORMED: <br />EW WELL BDRIN <br />0 SOIL BO -RING # _ <br />0 WELL # <br />Y <br />Township. <br />(CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') <br />COMMENTS( -'0Y I ('P / - <br />Range Section <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE ; !/ a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: Aver <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS IV 1,4 TYPE OF CASING: 0 STEEL a PVC 0 OTHER: <br />a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL j iV7?,P2 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE XPUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS��b r><IauN Gc it �s.-r <br />OTHER: C Pr 0 OTHER APPROX. BORING DEPTH 2 2 S a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED/ A (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 the work will be done in accordance with San Joaquin <br />County Ordinances((,, �Rules and Regulations, and all applicable California State Laws. <br />Signed x n~_ �J l Title/Company S4-/�/tt�VCJw"_'D J!�; - <br />6� <br />Print Name 01 Y1 12 lyI �' 1 V x 60- C Date 12 / 0 1 / 0 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />/ Or -to be r .70 - 2004 <br />V <br />Application Accepted �BY�I C +O r 1 4 L, M C Lt r fn e N Date Issued 9 2 004Area , <br />Grout Inspection By�► i1c ,L�s, Date )2-14104 Final Inspection By ate / —/ 3 OS <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: A e m e ri lg -F 4 C P r e r; na s, C P T- <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE PERMIT / SERVICE REQUEST # INVOICE <br />35o I 89.00 '4` 89.00 <br />SR# 00 0423 <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit_ Encroac m oc_ <br />EHD 29-02-001 <br />6/22/04 <br />