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t„ <br />4 <br />San Joaquin County <br />Enty rulnmentai "earn" "elpartmeinif <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468.3433 Web: www.sjgov.org/ehd <br />Well Permit Application <br />NON-REFUNDABLF PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 Nvelopm4nt Title, Chapter 9-1115.3 and the Standgos of can Joaquln Countv Ft-Ironmental Health DPnerirrP,f <br />Assessors <br />WELL Locstlon 6 t ri r 'ruy pt,Cross Seet City Zip Qom!P`_I:.5_Parcel <br />AIDS FAC I <br />PROPERTY pQ n <br />Owner Lflt/ &7.Z"D Address [Z 1�/� PSP City ,Zip Phone* ZOO IN 0641 <br />FEE INFO <br />C-57 Contractor&"0 9 <br />dress A- �Llc#? jPhone# 1 ' N300 <br />`IlAf 9,V <br />CHECKS <br />{ <br />/► <br />City��U4 Phone#�0,��„�11 <br />Consultant / Sub Cntr A-rG ASQ (JATJ�S Address_ fill jhjE &A yeaa <br />DATE VEST s <br />gR <br />�sb <br />G18 Coordinates: X , Y Township_ 0YV Range Section <br />3 <br />I o5S <br />•I <br />VQtKT0 51 PERFO MIW. <br />g NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) p DESTRUCTION (choose type Below) <br />\` <br />BOR <br />0 SOIL G * 0 OVER -BORE. DIAMETER <br />j WELL * _ 0 PRESSURE GROUT <br />0 'OttlWr GROUT SPECIFICA T TONG <br />COMMENTS. <br />TYPE OF WELL INSTALLATION TYPE G0N9TRUC <br />MONITORING I HOLLOW STEM DIA. OF BOREHOL a 0 MULTIPLE CASINGS I) MULTI-LEVEL WELL CASING DIA' �a� <br />p EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS&A 90 TYPE OF CASINQ; 0 STEEL I PVC p OTHER: <br />! VAPOR [] MUD ROTARY DEPTH OF GROUT SEALI.-a__m_JD' TREMIE TYPE TO BE USED. Ll AUGERS I HOSE <br />u nen o -n izu v.(-vlvc u i-vori runsi I tur UI t.r- I )Q. KVV I .'3,CML rUMrCu: E Yes U NO mite I C: rMMA1MUM mr-r--iiALL u1=r 1 Ft 10 au-) <br />o SOIL BORING 0 HAND AUGER GROUT SPECIFICATION$ 0"—r <br />9 OTHER: _O OTHER.------__-- APPRbX- pr�rnla OLPTN A�-�- _ a,C TEn rgFFIC 'O -�; ' STOVE PIPE <br />CONDUCTOR CASING PROPOSED ljD (it 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 c.ortl`y that I have prepared this appiication and thAt the work iwiii loud bone iri accordance Wii:in man Joaquin <br />County Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x Title/Company✓ <br />Print Name <br />Uth'Aht I MLN 1 USt ONLY <br />SITE MAP IN UNIT IV FILE, ADDR SS: (G-_;3.oZ 4-b <br />WORK PLAN DATED: 1- (}S��L►�-� .��_-_._ .�.� <br />Application Accepted By Date Issued"rI <br />___`�rouc mapearon ey Uate a U5 Final Inspection By Ci Date <br />1xe <br />Destruction Inspection Ry !?ata+ <br />COMMENTS I CONDITIONS: <br />ACCOUNTING ONLY. <br />AIDS FAC I <br />PE COVES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECKS <br />RECD BY <br />DATE VEST s <br />INVOICE <br />�sb <br />3 <br />I o5S <br />SR*oc,43 (o o <br />C-57— WC --WAIVER_ C-57 Letter of Authorization to signpgr►nit_ nt miwt <br />EMD 29-02-001 <br />6122/04 <br />Ze 39dd Did ois3coN SZZZ-SLS-612E, Sb:ZZ SOOZ/SZ/80 <br />