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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: www.sjgov.o�(�k <br />alloy <br />Well Permit Application <br />SITE <br />MITIGATION <br />_1; PiN 2: WIT IV <br />NON-REFUNDABLE PERMIT EXPIRES 7 YEAR FROM DATE ISSUEDL i4 y I[,) C R,(1 I E N I- A L <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work describ6 47iij dlpiOdat%n R i1WCfe36 kompIlance 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 Locatlon 13 S SC G�or c Cross Street 3lty" t �SC c,S <br />City cion Zip l3Z-b Parcel# <br />PROPERTY u 1 <br />Owner___C_ �krj OF E.sc.�\'z" Address P O g�K 1�� City CSCC'11°^ Zip 0153-LoPhone# <br />� leo "19 <br />C-57 Contractor\�4 000w o.,k Address Q City -io V �c1 Zip�ys ILic# Phone# )-I D <br />Consuita t/ Sub Cntr�cc�9._'CL�,..�i4ddress \l01 —1"1'� S-1 City 411zS'1� Lic# — Phone# Z SI2 `i`\°� <br />GIS Coordinates: X _'Y Township Range Section <br />WORK TO BE PERFORMED: <br />AID# <br />FAC# <br />D NEW WELL/ BORING PT, GEOPROBE, <br />HYDROPUNCH, HAND -AUGER, OTHER") fIDESTRUCTION (choose type below) <br />FEE INFO <br />D SOIL BORING # <br />_ p OVER -BORE. DIAMETER <br />REC'D BY <br />0 WELL # <br />PE ST # <br />II PRESSURE GROUT <br />` c� <br />D `Other <br />�33 'o C' <br />GROUT SPECIFICATIONS <br />G� <br />COMMENTS: <br />SR 00 -+0S <br />(e. �% �19y� 11 ) OS Ct m 61 <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />'MONITORING <br />n HOLLOW STEM <br />DIA. OF BOREHOLE 9-10" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: Z," <br />n EXTRACTION <br />D AIR HAMMERIDRIVEN <br />CASING THICKNESS TYPE OF CASING: D STEEL '57PVC 0 OTHER: <br />`fVAPOR <br />IID <br />n MUD ROTARY <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS D HOSE <br />AIR SPARGE/ OZONE <br />0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 31)1) <br /><_ <br />n SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS Ni¢ovi- u w�E✓�/i"' <br />� <br />D OTHER:_n <br />OTHER <br />_ <br />APPROX. BORING DEPTH L3"ls5� }s90 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />0 - _ (_ _ 1 I - <br />/- i / -1 1-_ _ _ . / — _I - I _ - / A ` <br />\ '" <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 xL��-�G� �+—y LTitle/Company <br />Print Name 0-o N G V_)UC l �) ('k" R ia_ S Date % �� % <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 13 Of <br />WORK PLAN DATED: SZ I I I IA < <br />Application Accepted By , ��n,l �,� Date Issued_ ) C' Sl_ _Area <br />Grout Ins <br />ection B (/l�,� S <br />Inspection y ..� ati Date_-, <v vt� Final Inspection By _ 1j.i,w���,, Date __U O <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PE ST # <br />INVOICE <br />3 4-oZ <br />56o.oc <br />�33 'o C' <br />ol��� <br />G� <br />l,r � o <br />SR 00 -+0S <br />C-57_ WC --WAIVER, C-57 Letter of Authorization to sign permitcroochment <br />EHD 29-02-001 <br />6/22./04 <br />3 X03 z�� <br />