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San Joaquin County <br />OXG'l 2 M <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <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 />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 />jj �-`�-.. /���'" � Assessors ^ <br />TEtt�ldCatiortl3)/�t.S),pki4ALe-A),�-9pacrossStreet /4,t,WELX, City TeeK-AD Zip 202 -Parcel# P, fit <br />PROPER Y LL c <br />J ddressZ lp c�o City S10Ck� Zip Phone#Owner 1y D .% 9j 4 <br />C-57 Contractor )SCA 21LL7 1G_Address '39? 5*N&RI tI P CityicVM5Phone#6k77Z-3bi�) <br />Consultant/ Sub Cntr(p5AQ>2. 6*ZW T"- I ddress jft f Mgg 1dEST Cj9,' City S7W:j:J� Lic# Phone# W Z ^D S- <br />SuIrA T <br />GIS Coordinates: X , Y Township Range Section C <br />WORK TO BE PERFORMED: <br />VVEt1L / BORING (CPT, GEOPROBE, YDROPUNCH HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />OIL BORING # 3 TD ^-35 r 0 OVER -BORE. DIAMETER <br />0 WELL # 0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />C0MMENTS�� ous Rem tl~ 5JcE►iD kk Ul(r16A)5 X{ Of 5'-71 7-010 <br />TYPE OF WELL <br />[] MONITORING <br />INSTALLATION TYPE <br />0 HOLLOW STEM <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE —Z'I [] MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />FEE INFO <br />0 EXTRACTION <br />IR HAMMER/DRIVEN <br />CASING THICKNESSAVA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />3sv <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL Aa, TREMIE TYPE TO BE USED: 0 AUGERS <br />[] AIR SPARGE/ OZONE <br />0 PUSH POINT (GP or CPT) <br />GROUT SEAL PUMPED: es 0 No NOTE: MAXIMUM FREE -FALL DEPTH IS 30 <br />VOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS TyI�G'VR_i1164TGfi)IM1EIU7 GoNcx[:TG F"//y/56a <br />3)V THER: j4y�0 OTHER <br />APPROX. BORING DEPTH -v,35' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />/ 1 / <br />CONDUCTOR CASING PROPOSED (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 thi application and that the work will be done in accordance with San Joaquin <br />County Ordin es, Rules and Re rations, and all applicable California State Laws. <br />Signed x Title/Company LOGJ (fOR113G12.�A9ZT.er�ccr�lEg,J� <br />Print Name - �Y �/ D Dater <br />DEPARTMENT USE ONLY ( f / c <br />SITE MAP IN UNIT IV FILE, ADDRESS: Ile, e, (-ML h J le— u-� ��! c c� 1 ` l L o 61 o t k of (r 1' 17t St <br />WORK PLAN DATED: M et V I et 2006, <br />Application Accepted By Vj 4A 0 f, i a Lr i 1 L Date Issued 2G —Area�� <br />Grout Inspection By Date - ,OG Final Inspection By j Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: AdVati of <br />J I 1 'n <br />1412- 3 <br />n (,Yal2} <br />tree <br />ACCOUNTING ONLY: <br />AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE RVICE REQUEST # INVOICE <br />3sv <br />vc <br />�� <br />, <br />�-� vG <br />SR# `'C g44 <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit_ Encro oc_ <br />EHD 29-02-001 <br />6/22/04 <br />