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6 <br />Pau''M San Joaquin County <br />A 2Efivironmental Health Department <br />r° •r <br />{RONV, H �t_Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />PEP��I�I14�9 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <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 Title, Chapter -1115.3 anndI the Standards of San Joaquin County Environmental Health Department. <br />c11 { ���• �7� 1 IBJ- City �D�t7 Zip 9Assessors <br />WELL Location `p� U)1�=-1 � Cross Street � � Parcel# <br />PROPER, /1 1 (�1• 'L� �,f� <br />Owner ✓) %\ (`- Vii.^ Address (l�� I �� J� City._ ,t C �4--- Zip /' Phone# i 7 VJ ,—yi3q's . <br />! <br />C-57 Contractor Li e - h I I `L'1C Address 1 7V D:i l+ tC Cit l� i �Y7 Lic# Phone IZj 3i 3 �x� <br />Consultant/ Sub Cntr_?",S li^ a^ bbul Addres-Al l'I: tfYi')f•� City) yl r( ,vy ,_ 'c#y8�/bJ Phone# 6 C 1L <br />GIS Coordinates: X Y Township Range • (U Section <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />0 SOIL BORTQ1 G # , 0 OVER -BORE. DIAMETER <br />ELL # M4U ——mww It[] PRESSURE GROUT <br />* ther GROUT SPECIFICATIONS <br />COMMENTS: _ <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING HOLLOW STEM DIA. OF BOREHOLE �� 0 MULTIPLE CASINGS [] MULTI-LEVEL WELL CASING DIA: �•_ <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS D TYPE OF CASING: 0 STEEL'AVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ��Jt TREMIE TYPE TO BE USED: 0 AUGERS HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: �j es 0 No (NOTE: MAXIMUM FREE-Ff4LL qEPTq IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER: [] OTHER APPROX. BORING DEPTH OLTED 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 cUd <br />ave r pared this application and that the work will be done in accordance with San Joaquin <br />County Oul d Regulations, and all applicable Californi State Laws. <br />Signed x Title/Company '11G('- �l \ AL3 i1Ct? <br />Print Name v7v­,1 �Y �(: I Date 7r <br />DEPARTMENT US):- ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: N` <br />WORK PLAN DATED: r0 hr <br />Application Accepted By Date Issued ✓ Area V v <br />Grout Inspection By Date Final Inspection By Date F--54 S <br />Destruction Inspection By Date <br />Ax— <br />COMMENTS / CONDITIONS: <br />C-57 V/ WC -"' -WAIVER C-57 Letter of Authorization to sign permit_ Enc <br />EHD 29-02-001 <br />6/22/04 <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE FERMI U # <br />INVOICE <br />-Z sR# <br />C-57 V/ WC -"' -WAIVER C-57 Letter of Authorization to sign permit_ Enc <br />EHD 29-02-001 <br />6/22/04 <br />