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San Joaquin County ORIGINAL <br />Environmental Health Department SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.co.san_j_oaquin.ca.us/ehd UNIT IV <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 />W// .. l -r1'� �A �-33-)3L <br />Assessor <br />WELL Location QS+ K-/ Zk ross Street City QL Zip 3% Parcel �ay <br />PROPERTI*, -0��2 / <br />Owner t Gl%- Address�� li City 0. Zip //JJ.�,k9hone# / 2 <br />C-57 Contractor I L I I Address olA r- n CI ity�1J�LSLLic#hone# q COJ -35�� 3 <br />Consultant / Sub Cntr _ Address '9 3 7 �JVLU ..� p� City j� Lic# L �0 % Phone# � / % % —/66 <br />GIS Coordinates: X , Y <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING <br />0 SOIL BORING # _ <br />—QnNELL #�_ <br />Other <br />COMMENT <br />Township <br />(CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />Range Section <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 />Xl MONITORING HOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br />///0___ EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS Yuri TYPE OF CASING: 0 STEEL "IeVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CFT)GROUT SEAL PUMPED: 0 Yes �nlo (NOTE: MAXIMUM FREE/ -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Ol'} 1Q t�1r02 T -Ff— <br />O OTHER: --0 OTHER APPROX. BORING DEPTH o1Ol �BULTED fRAFFI BOX or ]STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <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 Title/Company - Vl'U�O <br />Print Name oyw\\ " 5 e—,KDate <br />SITE MAP IN UNIT IV FILE, ADDRESS:fl_ <br />WORK PLAN DATED: '3 -0 <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection B <br />COMMENTS / CONDITIONS: <br />DEPARTMENT USE ONLY <br />fo <br />Date <br />_Date Issued_ <br />Final Inspection By <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMI S QUEST # <br />INVOICE <br />o <br />' PA <br />SO <br />7 2� 'S R# <br />C-57 WC= WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br />EHD 29-02.001 <br />9/30/2002 <br />