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,3an 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 />1%6%09418 loom <br />0 &'M K I <br />Well Permit Application <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 Ti Iter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />WELL Location I 1 11J `�ti(()-��ossStreet WQIG- AA Cit 34 Zi <br />Assessors <br />y p���arcel# <br />114— <br />Owner— c(t` ' SAOL-0-"Address ,JVs 0 C— t J,001 city\ amu'-I�`Zip aPROPERTY (ko �Phone# ^� ' l E l o <br />rsss3s )Sm' y Po e# TC-57 Contractor r1Ede)Ci� 4 Q <br />Consultant _ QU <br />/ Sub <br />Lic#'706Phone# T(�q�� I oL' c <br />U _ 114xtSco <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING (CP , GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER") 0 DESTRUCTION (choose type below) <br />SOIL BORING # " -- 0 OVER -BORE. DIAMETER <br />WELL # 0 PRESSURE GROUT <br />0.Other GROUT SPECIFICATIONS <br />�. <br />COMMENTS: Ao V7,n � 1� <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: 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 />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 />hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordin77;m <br />nd Regulations, and all applicable California State Laws. , / ) /� f <br />Signed x 't, <br />Title/Company I✓ LY aC�jLd <br />Print Name J�r� �l . T V X ;r,i _ 67. -7 0 Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 1 30 Noy-+- t 14 u n+er S+ree+ <br />WORK PLAN DATED: 1Jj3 71 U /5 r .i 20 i 2 0 0 5 <br />Application Accepted`/By T Date Issued 31 0 S Area 14S 9 <br />Grout Inspection By 11 i thri 4 melhef Date .212/()5 -Final Inspection By ate 2 / VOS <br />Destruction Inspection By Date <br />COMMENTS/CONDITIONS: AdVa-AaOmen+ al set 1 100r1Y1A5 _ S13-6, a4 S15-1_ <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE PERMIT / SERVICE UEST # <br />INVOICE <br />3501 <br />89.00 9,? -00 <br />SR# 00410 G!v <br />C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_ <br />EHD 29-02-001 <br />6/22/04 <br />Z <br />