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San Joaquin County <br />Environmental Health Department SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED L <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 Devejlopment Title, Chapter 9-1115.3 <br />and the tandards of San Joaquin County Environmental Health Department. <br />I �© / V . i T L1 ' ' ���� �✓ City cc p -Assessors <br />WELL Location l Cross Street J 0'(\ Zi arcel# i ,3 i1 Z M <br />PROPE�Ct, <br />Owner <br />:5+C),C Address^— Zio9 S� Ine# C p / <br />O <br />City_ <br />C-57 Contractor=01r,/\lj� L�1` a3(o l l> tr �'.l{f, V� 1 r i a <br />ddr s � �, ny �r' Z' ,� �Lic# �5 �r ' /(b`,�— T-111- <br />Consultant / Sub Cntr � T -111 - <br />Address 5 0� '' �� ty t-YO�L � �OIolC3 Phone# -915q Saq <br />GIS Coordinates: X Y Township Range Section <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 />DESTRUCTION (choose type below) <br />OVER -BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />PE CODES <br />MONITORING <br />0 HOLLOW STEM <br />DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />REC'D BY <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE <br />0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS <br />0 OTHER: <br />0 OTHER <br />APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />? <br />CONDU TOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: 11n',l�S <br />DJOI I� 'f i�r- <br />U+ (,t -W <br />_ �� � �,fi� rZ b <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 <br />County Ordinances, Kies <br />Signed x. <br />Print <br />I this application and that the work will be done in accordance with San Joaquin <br />ulations, and all applicable California State Laws. <br />C-, . <br />Title/Company �/ L�[ Q(� � Q r c) I a <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 1 ,� Q N Q r i �) f t o i j C i^ Si f' ee f <br />WORK PLAN DATED: J4.)j1)-It c; / , ;2Ce7 <br />Application Accepted BGv _ Ale (.-1, 1, h E ] Date Issued l! i 1 ,: ' ' '- Area_L <br />Grout Inspection By Vj 4yii-Ya L, 1YlC4tLDate ^ Final Inspection By i/' h1 Date 2 8 105 - <br />Destruction <br />0';Destruction Inspection By Date <br />COMMENTS / CONDITIONS: Ji'cr' 1 1 �! Ll'tii L. 2 <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 / SERVICE R ST # <br />INVOICE <br />(t r-4 I E12i <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit_ Encroacm — <br />EHD 29-02-001 <br />6/22/04 <br />