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San Joaquin County <br />Environmental Health Department L <br />SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehkPR -• 2 2007 UNIT IV <br />Well Permit Application ENVIROK-L-j,i f ty AJH <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDQERMIT/SEgVICES <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 Standards of San Joaquin County Environmental Health Department. <br />f� ( Assessors `) I) / M 1 <br />WELL Location / 3 %, 3 Cross StreeF-1 City � / 4j Zip IS Parcel# V 1 U DO <br />PROPERTY <br />�� I i1�iC S;7U ` C G� <br />Owner ��IIir''+�r nn L'-Zrr2�Z�// Address kcZ L. /Sc City C Zip 1��I�Phone# C ��r y <br />C-57 Contracto QVLI.Cl� � %% �l Address S�S� /7� JTCity4K"Zip��� Lic# Cl)'% Phone'#� <br />Consultant/ Sub Cntr ft �L/ 1Address / L,^�l %/ N� 3� CilyM P Lic# Phone#l�L� <br />GIS Coordinates: X 'Y Township 1 Range Section <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING <br />0 SOIL BORING # _ <br />P WELL # <br />0 'Other <br />COMMENTS: <br />(CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING I HOLLOW STEM DIA. OF BOREHOLE_J°L 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS L) TYPE OF CASING: 0 STEEL I PVC 0 OTHER: <br />VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 6' TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: I Yes D No (NOTE: MAXIMUM FREE -FALL DEPTH IS 31 <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS ZJ -'6 6 ?� <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH 310 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED Z! (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 certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinances, Rules and Regulations, and all applicable California State Laws. <br />{✓J , <br />Signed x Title/Company 14041 <br />Print Na <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 0 <br />WORK PLAN DATED: /� U1 , Cha �� <br />,- <br />Application Accepted By Date Issued / S/C' Area % <br />Grout Inspection By - Date G O Final Inspection By 'W1 Le�� Date d <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PER UEST # <br />INVOICE <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit_ Encro <br />EHD 29-02-001 <br />6/22/04 <br />