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San Joaquin County <br />Environmental Health Department <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-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <br />Application is hereby made to San Joaquin County for a penult to construct and/or install the work described. This application is made In compliance with San <br />Joaquin County Development Title, Chapter 9-11115..3 and the Standards of San Joaquin County Environmental Health DepartmentAssesL <br />. <br />WELL Location ] <br />_ <br />`� W r" , Et QQ J-GfL 57• Cross Street City _ZIP � D arcels�D/ (� <br />PROPERTY I W)1 �'�gai grid�Cwr G��k <br />Owner I ril Address City 5666V) Zip 1521 Phone# <br />C-57 Contractor O W Ali (o Address <br />, ssi 7pcwPhone# <br />d %�0 <br />Consultant / Sub CntrVI .0s( Adat7 <br />CGSy� City �''t S <br />`) �, syr 6 Lic# Phone# <br />GIS Coordinates: X 3g. Z) 21 Y_ _14,12—k-31 7L L�5G9Z <br />Township Range Section <br />WORK TO BE PERFORMED: <br />p NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER•)ESTRUCTION (cho <br />a ose type below) j <br />SOIL BORING # . 1 1J <br />Q WELL # PER -BOREDIAMETER <br />RESURE GROUTit <br />0 'Other GROUT SPECIFICATIONS <br />COMMENTS: byt, i1LI VW -1 <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />a MONITORING *OLLOW STEM DIA. OF BOREHOLUIIUI) a MULTIPLE CASINGS 0 MULTI-LEVEL WELLCASING DIA: I <br />a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS 5 A.gD TYPE OF CASING: p STEEL �4VC 0 OTHER: <br />XAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS a HOSE <br />a AIR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: Q Yes a No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br />a OTHER: fl OTHER APPROX. BORING DEPTH Q BOLTED TRAFFIC BOX or Q STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications In comment section) <br />COMMENTS: <br />A <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 Californiia/ODS�1 a State Laws./J <br />Signed x 64 <br />Title/Coman <br />lilA jj 511J-5 <br />I 0 P Y �Vly✓on a, �ya 1, <br />Print Name____ 5(h+4 �3� A,,r/ Date_ 10-2-0-7 <br />DEPARTMENT UCCS/nE� NLY D_ LDp <br />SITE MAP IN UNIT IV FILE, ADDRESS: O,6 N <br />WORK PLAN DATED: 6 <br />Application Accepted By Date Issued Area66 <br />Grout Inspection By Date Final Inspection By <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY DATE <br />PERMI EE REQUEST# <br />INVOICE <br />KID <br />C-57 WC= WAIVER_ C-57 Letter of Authorization to sign permit_ Encroac ment doc <br />EHD 29-02-001 <br />6/22/04 <br />