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San Joaquin County n������ <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 9A_ 2 1 2006 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sj91?NVRA91EN T HEALTH <br />Well Permit Application PERMIT/SERVICES - <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />SITE <br />MITIGATION <br />UNIT IV <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 Standar Wi San Joaquin County Environmental Health Department. <br />%D Sd f' NIC/�iGti< Q� /Ill/;v: J _ / y P 9.iL/ Assessors e� 270 .. 03 <br />WELL Location ross Streets K1� Cit Zi Parcel f3 <br />PROPEPgXIYY ••>� 4 p.�Pvt�f "` �OSOa �L%si/�,.P/2�( ~a,.�.A `�S Id/ 2.0 ' 9 2' S/�.So <br />Owner this • `,^,� •� Xddress ,` City Zips} Phonle#� <br />�% W `��•/f'wrAddress?�! Q�%� T1iP City��rC�ir� 754 `� rw �Z ay /sv <br />C-57 Contractor Zip ic# Phone# 7/G 977 y <br />Consultant/Sub Cntr V& 11-&-'k � atAddress�ds� S^r Cit e Lic# Phone# '?"e' .7-72 l ql y <br />GIS Coordinates: X , Y , Township Ran <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING <br />0 SOIL BORING # <br />0 WELL # <br />0 *Other <br />COMMENTS: <br />(CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />Section <br />DESTRUCTION (choose type below) <br />VVER-BORE. DIAMETER <br />ArRESSURE GROUT <br />GROUT SPECIFICATIONS <br />/V1 w / AA w 8 <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE [] MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 4PVC 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 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <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 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 / /f"/� Title/Company 4 <br />Print Name Date �/ <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADD ESS: <br />WORK PLAN DATED: y % % , ?�C� <br />Application Accepted By "1A_t0 Date Issuedf� / �� Area <br />Grout Inspection By Date Final Inspection By Date <br />Destruction Inspection By Date J� U(, <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT # <br />INVOICE <br />(12 <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit_ _ <br />EHD 29-02-001 <br />6/22/04 <br />