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San Joaquin County <br />Environmental Health Depart _� SITE <br />600 E. Main Street, Stockton, CA 9520:310 L ���Lf MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV <br />Well Permit Application MAY 1 0 2oo7p, <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM 9k"' 9 't� NT HEALTH GP <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work' desis 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 3/S a/ceea %`! Sal' Cross Street Zi X7' S"T. City 7410' Zip s� 324 Parcel# <br />PROPERTY T'Z#'1<r ✓4"IA"T <br />OwnerUN/F/�rD SC/IQOG 01J'r. Address 475 A(/ 44A/44 —Cit /W",- ZiPWX Phone# <br />c9's�7o <br />C-57 Contractor Address Set/ Ti�iw P/1eA�f Oe. CityA,yTOS Zip`$'#0J Lic# Phone#g3!-LLL •sc/7f <br />Consultant / Sub Cntr e,P.if Address2ol [/AL aaf V Atfd/ City fl09.t.-tW Lic# Phone# !t -S'tS -GtYy <br />GIS Coordinates: X Y <br />WORK TO BE PERFORMED - <br />0 NEW WELL / BORING (CPT GEOPROBE HYDROPUNCF <br />0 SOIL BORING # <br />0 WELL # <br />0 *Other <br />COMMENTS: <br />Township Ra <br />Secti <br />HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />0 OVER -BORE. DIAMETER W <br />0 PRESSURE GROUT _ <br />GROUT SPECIFICATIONS til <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />AMOUNT REMITTED <br />0 MONITORING <br />0 HOLLOW STEM <br />DIA. OF BOREHOLE 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 0 PVC 0 OTHER: <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE TUSH POINT (GP or CPT)GROUT <br />SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS ��irKiGlf �t�s h++iTe <br />0 OTHER: <br />0 OTHER <br />APPROX. BORING DEPTH /-4" cf ? 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 Ord�Vnces, Rules and Regulations, and all applicable California State Laws. <br />Signed x ger. <br />Print Name <br />SITE MAP IN UNIT IV FILE, ADDRESS <br />WORK PLAN DATED: /1 <br />Application Accepted By. <br />Grout Inspection By_ <br />Destruction Inspection <br />COMMENTS / CONDITIONS: <br />Title/Company 40AM-MW.R -AMMA; efOC/dTlf <br />S <br />DEPARTMENT USE ONLY G� <br />-/S E. //'Vok SY <br />Date <br />Date Issued -6V, (0 d <br />Inspection By e — <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT / SE EQUEST # <br />INVOICE <br />sR#X56666 <br />C-57 ✓ WC ✓-WAIVER_ C-57 Letter of Authorization to sign permit_ Encroac men oc /r <br />EHD 29-02-001 web <br />6/22/04 <br />