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Q9 <br />San Joaquin Countv <br />Environmental Health Department <br />�as all <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 9202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: rAwNv.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 />4.0 <br />Application is hereby made to San Joaquin County for a permit to construct andior 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 />WELL Location c%4;_ L -0c !2t (� �k f_ - j L� Cross Street Assessors <br />city t: G Zip - t2 arcet# ; 3' j jo C <br />PROPEt1Y <br />Owner .) ^ tG z_.v�C< L� AddressCityt Zip' � y� Phone# �' �% <br />r -�o� y <br />C-57 Contractor � L�d Iti`A'Address i`I4 f 1 �e_ ��t City( _dn Y� ."� Zip c� 'jai Llc#fC 7 iti7 Phone#__.raj_ � 0_ <br />Consultant i Sub Cntr I J (21 <br />11 Address _�` �,- - Cityr>1 G ttf'v�Lic# (oeO=� L ) Phone# vel J �1 h J - /6Zk7 <br />GIS Coordinates: <br />Range Section <br />WORK TO BE PERFORMED: <br />`°IYNEW WELL/ BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />71 0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />�&WEI_L# ? c} 0 PRESSURE GROUT <br />0 `Other GROUT SPECIFICATIONS <br />COMMENTS. <br />TYPE OF WELL <br />INSTALLATION TYPE <br />MONITORING <br />`�rHOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE! OZONE <br />0 PUSH POINT (GP or CPT <br />0 SOIL BORING <br />0 HAND AUGER <br />0 OTHER: <br />0 OTI IER <br />COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLES 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />ir _ <br />CASING THICKNESS --47,V\, 9,C_) TYPE OF CASING: 0 STEEL APVC a OTHER: <br />DEPTH OF GROUT SEAL �2t TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />GROUT SEAL PUMPED: 0 Yes �%No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />GROUT SPECIFICATIONS }4,� I / j _ <br />APPROX. BORING DEPTH 9 -Ur 0BOrLTED T FFIRA C BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED A, Q (f 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 ��'�,— _ 'Jy?C r� � 1� Title!Company 15 c",� <br />N Pt <br />Print Name Dow /�N Date 13 ` C`] 5 e�►nw.�l <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: �S G(/. !� t5y/ <br />WORK PLAN DATED: 1-i 7 - 0,5; <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />Date <br />_Date Issued lf/ —� 3 Area Q (� T <br />Final Inspection By %i - i Date 3 �s <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY DATE <br />PERMIT / SE VICE RE ST # <br />INVOICE <br />..�-., <br />- <br />7-2.3 C -r <br />C-57 ✓ WC= WAIVER ✓ C-57 Letter of Authorization to sign permit_ n ac44 <br />EHD 29-02-001 <br />6122/04 <br />