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San Joaquin County <br />ORIGINAL <br />Nrff%�4 <br />Environmental Health Department SITE <br />East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV <br />�ul 1005 Well Permit Application <br />ENVIR��ON�iMENT�jHEA LT�N-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application isi�t'r 41" Matl�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 />( SOL N. 6-i Der -Ad -It Cross Street i y) uwti City -i4,` p�Aarcesors 1� <br />WELL Location � �� Zi S� Parcel# (�� ?-C.370- <br />PROPERTY pp <br />Owner (CA LO?1Li1/rb Address �rKd 1Li(!�jollhYr+a{ 4City1--! t -e- . Zip 4;0?Phone# ./-/ .4 <br />C-57 Contractor 4.sc,.d, D/1((,tiS Address 3G's2 Q ke, Crc i.< iCity�a 6-- dip S ic# 7/7S/OPhone# (�^ <br />9 G�f -V6 � <br />Consultant / Sub Cntr 5CC6I +„t,,, \ Address -'X)' 7 `� �5ly- - P� City -4. «``�Lic# dA Phone# e'>0*%) 50-{IYct <br />GIS Coordinates: X , Y <br />Township Range. <br />Section <br />WORK TO BE PERFORMED: <br />/NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') p DESTRUCTION (choose type below) <br />[] SOIL BORING # 0 OVER -BORE. DIAMETER <br />[ELL # IUM) 4 tiluJ !% 0 PRESSURE GROUT <br />'Other GROUT SPECIFICATIONS <br />COMMENTS: .7�6-ro 1G ryu k pit, &- tie tf -T;;� 4 A. (/c. Ai«, " G�. � � r�c•�� _/Z/ 2c� <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />�Q MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE Ssz 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:___ <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS�[.�� TYPE OF CASING {j, <br />0 STEEL �PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL l C � TREMIE TYPE TO BE USED: 0 AUGERS f HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: OYes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS e"Ae,4 <br />0 OTHER: BOTHER -h .\ t APPROX. BORING DEPTH U00LTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: (2 \ / v t� 14y1i ��✓ Vf-1(4 . Sck �/e M /a 12c � ,• / C .10ZC Lc, )Z 042&- i r r W--4 <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 R ulations, and all applicable California State Laws. <br />Signed x -y Title/Company 2n,,j t� kli -ti +-/ Oji (014 <br />Print Name Date 310Y 16 ) <br />SITE MAP IN UNIT IV FILE, ADDRESS:_ <br />WORK PLAN DATED: 3 -? "0 <br />Application Accepted <br />Grout Inspection By_ <br />Destruction InsDectio <br />COMMENTS I CONDITION <br />DEPARTMENT USE ONLY <br />50,7- A), <br />Date <br />_Date Issued D 5 Area Q d 7 <br />Final Inspection By Date � s <br />IV <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT / SERVICE REQUEST # INVOICE <br />iW� Vv' <br />7 <br />�v� �� �"�" <br />3.28 r- . <br />C-57_ WC ✓-WAIVER_ C-57 Letter of Authorization to sign permits Encroachment doc :� <br />EHD 29-02-001 <br />6/22/04 <br />