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San Joaquin County�rCr' � r <br />q <br />Environmental Health Department,4ijj- <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 />r� 3 21707 MITIGATION <br />NT HEALTH UNIT IV <br />I VICE <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 1Department. <br />Asessors <br />WELL Location _7�jfO L' W 61 D6'11�� 5�, Cross Street 11 glvli'm(r Le, Ig City 5/L'Lkirkl Zip Parcel# 6 74 35011. <br />PROPERTYVO <br />d I f^u5� `Li,F��1 8j-,AWcYIC ifc�t S C S.'ZI�) <br />Owner-Owner-I)IS1 AddressT �fl-Il ' [)C n �. Crt lin 4; hnn..ie <br />C-57 <br />)v (U . G-114, <br />Consuttant / Sub Cnttr-) T�ct�".� Cyl v l r0.1R1 i w( � -Ad( <br />GIS Coordinates: X Jo • o21 Y - Iu • �� <br />;itylt"l� Zip!S%k,) Lic#7C'55`1 Phone#-��-60-Z/JZC/ <br />Nkic# G 6(;8 Z Phone# 5 V -l! %& % z <br />Township Range Section <br />WORK PERFORMED: <br />NEW WELL/ BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER•) p DESTRUCTION (choose type below) 4-j <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER -SZ:4 <br />VWELL*n11L/-1 �L� LZi Z3 0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL <br />MONITORING <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS i <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY <br />OOLLOW STEM <br />DIA. OF BOREHOLE 9 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />INVOICE <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS TYPE OF CASING: 0 STEEL OVC 0 OTHER: <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL �S�- $.'� TREMIE TYPE TO BE USED: kAUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE <br />p PUSH POINT (GP or CPT)GROUT SEAL PUMPED: gYes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />O <br />0 SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS /lt'cef (epleJ <br />p OTHER: <br />fl OTHER <br />APPROX. BORING DEPTH S ' 1UC 0 BOLTED 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 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 />Signed x S L� 6tdTitle/CompanCN I, 'o,3� <br />Print <br />SITE MAP IN UNIT IV <br />WORK PLAN DATED: <br />DEPARTMENT USE ONLY <br />Application Accepted By Date Issued_ <br />Grout Inspection By lA�j�cu Date $ I I`f Ill C T Final Inspection By <br />Destruction Inspection By Date <br />COMMENTS/CON <br />m <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE <br />PERM SfRVICERE�UEST # <br />INVOICE <br />3.5-6 <br />`� B <br />133 b <br />SR'X3159/ <br />C-57_ WC --WAIVER— C-57 Letter of Authorization to sign permit_ ncroac ment doc_ <br />EHD 29-02-001 <br />6/22/04 <br />