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San Joaquin County <br />Environmental Health Department �� SITE <br />600 E. Main Street, Stockton, CA 95202-30�� MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov'?or"g/ehd 2C�� UNIT IV <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISS �` \�GFc� <br />ISR '+�� I�F. <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. ?F6i§`��iplication 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 />WELL Location I, 7o W M�w,nt, Lahr Cross Street Q v,� wail c ff trio Assessors V77 180 3 <br />City S�;A (( hJh Zip j Parcel# <br />PROPERTY- <br />Owner 5iv►�i-.LIPAFL' /' YA Address »t{ l;nco(v� �t^ City > kl�� Zip 95"''�Phone# logAl%`11A, <br />C-57 Contractor�`7% "'� b'lh N' Address Sio kwor Rut CitZip %71 1 710071 Phone# -70 1- 37q'g300 <br />Consultant/ Sub Cntr Sa � rA�,t iW V. Address b? 1) (amtson NAP,. CiSt'yo C1iMt.^V ^ Lic# Phone# 916 - b 17- 16" <br />AAek q S68Z <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />FAC# Q <br />ANEW WELL/ BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) p DESTRUCTION (choose type below) <br />FEE INFO <br />o SOIL BORING # a OVER -BORE. DIAMETER <br />CHECK # <br />)O VELL#0 PRESSURE GROUT <br />DATE <br />Other GROUT SPECIFICATIONS <br />iso l <br />COMMENTS: <br />�g.00 <br />l x(321-( <br />(A,( <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS I, <br />SR# F-)-2 <br />,'MONITORING HOLLOW STEM DIA. OF BOREHOLE $ a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br />a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS Ski W TYPE OF CASING: a STEEL OPVC a OTHER: <br />a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 2a TREMIE TYPE TO BE USED:.4AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: O Yes )kNo (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS Ii (tw�Rht` <br />— <br />a OTHER: a OTHER APPROX. BORING DEPTH 41)+ ,,g,1BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED h0 (if YES, list specifications in comment section) <br />N <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 Ordinance , Rules and Regulations, and all applicable CaliforniaStateLaws. <br />Signed /� Title/Company JET ✓-14-5 LAV"" ' vv1QN i G <br />rr <br />��� �ti�t�'�� «✓ 6 f <) 7 <br />Print Name /�i Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted B,w�Ccc L. Date Issued It D Area <br />Grout Inspection By Date Final Inspection By Date I <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />FAC# Q <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />li BY <br />DATE <br />PERMIT / S i INVOICE <br />iso l <br />�g.00 <br />l x(321-( <br />(A,( <br />I z/og <br />SR# F-)-2 <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign perni Encroachment doc✓ <br />EHD 29-02-001 web <br />6/22/04 <br />