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San Joaquin County <br />Envi amental 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 />SITE <br />MITIGATION <br />UNIT IV <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM NNEM93 M 2:07 <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:Fnvironmental Health Deppitrpent. <br />G <br />1O 0�7 �iLf �l t� �� ("1f�.�Ylb j, J�1tYf is : Assessors 7 t� <br />WELL Location Cross Street � City _± _ „ _ , , , � c P ;gyp" Parcel# <br />PROPERTY rr �Ck� p, I ]] <br />Owner C0"' 'l,'CY'!is�l( Address i�' 1.044k� { 1(0r City N Ziplzuvxc <br />Phone# <br />C-57 Contractor Address �' /•.1 (� ,�1�C City, <br />Consultant / Sub Cntr A(ht Address �1 1 K L+(i �1 City CIL N• Lic#L' 1'� '1,10 Phone# 4 b 7 - IG}6L <br />GIS Coordinates: <br />Y <br />Township, <br />Range Sectio <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />WELL # Ap. VV ' . 0 PRESSURE GROUT <br />] *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />„MONITORING <br />.HOLLOW STEM <br />DIA. OF BOREHOLE " <br />0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />` <br />CASING THICKNESS <br />TYPE OF CASING: 0 STEEL 19 PVC 0 OTHER: <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL_ <br />4 TREMIE TYPE TO BE USED: 'AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE <br />0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 <br />Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS <br />�G Vi1CLr Q <br />0 OTHER:_0 <br />OTHER <br />APPROX. BORING DEPTH <br />�� 1 X BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED I (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 Ordi n es,,Kules an lteg!J Ions, and all applicable California State Laws. <br />Signed x' t �-�-� Title/Company <br />Print Name w'�,Y 'I �' I �.�-C Date <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED-: /l <br />Application Accepted E <br />Grout Inspection By_ <br />Destruction Inspection <br />COMMENTS / CONDITIONS: <br />DEPARTMENT USE ONLY <br />_Date Issued AL V' Area <br />al Inspection By Date <br />Q T'ti <br />ACCOUNTING ONLY: AID# FAC# °✓ <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PE U <br />INVOICE <br />i <br />SRqjt4� <br />C-57_ WC -WAIVER_ C-57 Letter of Authorizatj16-to sign permit Encroachment doc <br />EHD 29-02-001 <br />6/22/04 <br />