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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: ww-,v.sjgov.orglehd <br />- Well Permit Application <br />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Dff- OF-r� <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 />Assessors <br />WELL Location t.�c t,UC .;�}- �� 1 r;i'tiR Cross Street 'H. °F �i_City eRL: Zipj,7 Parcel# jJ `>""• <br />PROPER 'Y n� <br />Owner ,' t1 "p---Addresslb7jv°Gav li cie r tfi k* City occ Zlpu <br />lhone#CAI <br />c— �,, _� y ' p` '•7':��✓13Lic# 1 �? Phone# <br />C-67 Contractor � ' -(, �T' , � Address�`1�`� til J}'(+r.l�� Cit �yL-�L�a- Zi <br />Consultant/ Sub Cntr vl� (n Address L 3 7 City 5.trL1•ksY'Y ic# (,ZO,-4a--) Phone# <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />$ANEW WELL / BORING <br />f ` 0 SOIL BORING # _ <br />-AWELL# <br />0 'Other <br />COMMENTS: <br />(CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER`) <br />p 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 />MONITORING AHOLLOW STEM DiA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WFLL CASING DIA' -11mllf" !� <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS `} TYPE OF CASING: 0 STEEL XPVC 0 Ol HER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SFAL—,# TREMIE TYPE 70 BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED; a Yes yNo (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS �L j x�a2_ j t <br />0 OTHER: _ 0 OTHER APPROX. BORING DEPTH BOLTED TRA(FIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED 1 ( (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 />1 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 Regulation , and all applicable California State Laws. <br />Signed x j / <br />g ��` ��- TitlelCompany�2+'"� (e)�1.5 d-� <br />Si��)� <br />()V�r� <br />Print Name Y� Vick Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 7 s JA/� /, <br />WORK PLAN DATED: A— Z%- O <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspecti <br />COMMENTS ICON <br />S — <br />Date Issued .:� 3 <br />Date Final Inspection By <br />Date <br />C-!0 P <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE P E UEST # <br />INVOICE <br />35� I <br />M <br />fit, <br />223 g <br />- to SR# <br />C-57/ WC_ -"'- WAIVER_ C-57 Letter of Authorization to sign permit v/ Encroachmen <br />EIiD 29-02-001 / /— 2— <br />