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Ain Joaquin County <br />Envirdommental Health Department SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.Sigov.org/elid UNIT IV <br />GINAL Well Permit Application <br />��' 25 <br />ED <br />NON-REFUNDABLE PERMIT EXPIRES5 DA I SUED <br />Application is hereby made to San Joaquin County for a permit to construct and/gr•jostall the work dpsc.ribi ad.YThis application is made in compliance with San <br />Joaquin County Developmen fc�q <br />Title, Chapter 9-1115.3 and the Standards of Sats uOr,vuRtyTngiroNtental Health Department. <br />?ill ) i Assessors <br />WELL Location �}�CJ e'llirjT— Cross Street Cit ' Ziq Parcel# l .3 Q3z O 13 <br />PROPER?��i Ofa-.5�04q.1ddresj�S�ne# <br />C-57 Contracto Addre;F632 <br />d11--ya: Zp5�2-tic#?�f one#�Ly / <br />Consultant/ Sub Cntr 7 T �%� Address ��� c ,A tq.AJ I�fi�City ✓Ilio# Phone# 6 ! /Odo <br />GIS Coordinates: X , Y <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING <br />0 SOIL BORING # <br />0 WELL # <br />Township <br />(CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER") <br />Range Sectio <br />W <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE. DIAMETER <br />0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ';01 //- 1 -c <br />MONITORING HOLLOW STEM DIA. OF BOREHOL w[fLTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />%r- <br />XTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS y ` TYPE OF CASING: 0 STEEL P -PVC 0 OTHER - <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALSO TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes__ 0� No//(NOT MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS ��K�'l I <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH 7.S t�-,l%I BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: 6%1 <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 (�[1� _ Title/Company 46-2,t <br />Print Name�v /r2''�iL� L��r/ CY Date <br />DEPARTMENTUSEONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: LodIV 6 <br />1- S <br />WORK PLAN DATED-: Se oto rn bar zq2 0 o S <br />Application Accepted By V",r_+troL L, M,-_(�a4riez4 Date Issued / 0 - z 7 - c S Area )45-'? <br />Grout Inspection By V `; #�r� i lde., /�R�� Date %� - �!� Final Inspection By 7 ! c �ar,u �'ld � r7ru� Date / I- 2 -0 S� <br />Destruction Inspection By Date <br />COMMENTS / CONDITIO <br />ACCOUNTING ONLY: AID# FAC# ' <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY DATE PERMIT / SERVICE REQUEST # <br />INVOICE <br />3s0! <br />'3Z5-03 <br />4.99 <br />1* 279 <br />368.00 <br />=�R# <br />C-57 WC= WAIVER_ C-57 Letter of Authorization to sign permit_ Encr <br />EHD 29-02-001 <br />6/22/04 <br />