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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 <br />Well Permit Application -0 <br />� �— 1 L <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 S ndards of San Joaquin County Environmental Health Department. <br />�0 ^ �,( .� ,� pAssessors <br />WELL Location / \! ) � a YC�ross Street (� City , } Ot�L Zip 15t f Parcel# / % d.2 t i. <br />POwne ERII'. Address ll)��Cl�i� �10J �itY f2C Z'' l5 Phone# 09 1 q o <br />J jam` ��, <br />C-57 Contractor_ ?(` (t> f (, �� Address_ O� i�v j �/\(� U `V It N CiittyyL -0C3'0�' ,Lip�(I � Lic#_5 0- 4oe(#/_3 cf <br />Consultant / Sub Cntr�itQQdLIAM Y IZol(U Address � ' " G� C►ty� (W' ` Lic#� hone# <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />AID# <br />0 NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) OESTRUCTION (choose type below) <br />PE CODES <br />0 SOIL BORING # DCVER-BORE. DIAMETER <br />AMOUNT REMITTED <br />0 WELL # %(PRESSURE GROUT <br />REC'D BY <br />0 *Other GROUT SPECIFICATIONS <br />INVOICE <br />COMMENTS: <br />- <br />6 <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />SR# <br />('MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 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 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 />< _ <br />CONDUCTOR CASING PROPOSED (if YAS, list specifications in comment section) <br />COMMENTS: wells irn/^/� )o +aTi otfd� MW �lfl &wE���� <br />rpt — p�4 r 3— <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR EN ROACHMENT PE MITS. <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, ule an egulations, and all applicable California State Laws,. <br />j f <br />Signed x 4 ✓ Title/Company <br />n <br />Print NameJrk-0 6-7 • �r% < Date <br />DEPARTMENT USE ONLY <br />l L <br />K6 ,r"�6, <br />SITE MAP IN UNIT IV FILE, ADDRESS: l .3 G' f-� Lf rl j,,r t51 ree.') <br />WORK PLAN DATED: ��r1� �; r vi 1 J. 2 n 0- <br />t <br />Application Accepted By la � G, i F L- Date Issued V i Y c•° 100 Area <br />Grout Inspection By i Y�Date Z Final Inspection By. ,F ate 8 OSS <br />Destruction Inspection By Date <br />t A <br />COMMENTS / CONDITIONS: {� (^ S ! i a/ \,-- c ) is � L / L� Lh YL >1!i Ly <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT / SERVICE EST # <br />INVOICE <br />6 <br />SR# <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachmen oc= <br />EHD 29-02-001 <br />6/22/04 <br />