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San Joaquin County <br />Environmental Health Departm <br />304 Fast Weber Avenue, 3rd Floor, Stockton, CA 2i3 <br />(209) 468-3449 Fax: (209) 468-3433 Web: w-"w.sj;ov.orWe}id.-1 2006 <br />-3 � / <br />SITE <br />MITIGATION <br />UNIT IV <br />Well Permit Application <br />ENVIRONMENT HEAL <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE tsspp ",r!T/SERVICES <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 />G -, -3 o E CcckCot� �. .� P'tr + Assessors <br />WELL Location f . '\Nc .e{ a f z t . Cross Street City S'C oZip 9 S Z'�y Parcel# <br />\ Pow -.dam S} . <br />PROPERTY E,l DJ a 11 <br />Owner Address L�45 N. 9 s t A City StJa toy\ Zip CAS 2-' LPhone# <br />CC <br />C-57 Contractor CS)r Address N,, Cityy, _ZipgZgoS Lic# '1 $`18Phone# l� - 9 S5 - i SS o <br />�-Consu I Sub entr G w\� �� Tc� WIU Address \\� \ ��� S ty� <br />___-1 a Ci 4"'6 Lic# Phone# 10 c S <br />GIS Coordinates: X <br />Y <br />Township, <br />Range Section <br />WORK TO BE PERFORMED: <br />p NEW WELL / BORING CP GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER") 0 D TRUCTION (choose type below) <br />% SOIL BORING # c-9 0 OVE -BORE. DIAMETER <br />0 WELL # 0 PRES RE GROUT <br />0 `Other GROUT SP IFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS _ TYPE OF CASING: p STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE! OZONE / PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />S SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER: _.-__0 OTHER APPROX. BORING DEPTH 11 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: �� i a,-\ -3 <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 I nd Regulations, and all applicable California State Laws. <br />Signed x Title/Cornpany �� 6•`�� %G//Yvt.q�r�_ _� <br />Print Name Wo, <br />DEPARTMENT USE ONLY <br />SITE MAP 1N UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By �• Date Issued Y/ ,_r�!r!" Area. <br />Grout Inspection By y Date_C. al Inspection By Date_ <br />Destruction Inspection By' " ` Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# <br />FAC -9 J )2-" < 6—, _ <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DAT <br />PERMIT / S <br />INVOICE <br />SR# <br />9 <br />C-57_ _ WC --WAIVER^ C-57 Letter of Auth4zato sign permit_ Encroachment doc____ <br />EFID 29-02-001 v <br />6/22/04 <br />