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RECEIVED APR 1 5 2005 <br />San Joaquin County <br />Environmental Health Department�a � "'� � <br />l E� il_ I )i SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: w1Aw.sjgov.org/ehd 2p05 UNIT IV <br />"�=--R"` Well Permit Applicationr�V�r�c��J�,vENr <br />i4,-ALT.q <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 />Assessors <br />WELL Location Ll L I W . 6emi ,I h4 5t - Cross Street ! _ i t_ City 140, K VCv ', Zip Parcel# I bJ G <br />PROPERTY VC1,wVlow'E_ <br />h <br />Owner (^, <br />. ;; ,_;lGl ) Address �yG� : ' fnll� * City'N rk+cZipci2 Phone# ( Lx ' I ((j(G - 0/3� <br />C-57 Contractor_ ('l QCi \ XI k1 10C Address ` ISL �lua %)� (� City rely l'L Zip' l y ::Lica ° (f�� IIGSPhone# a53 - Q C C, <br />AID# FAC# <br />/SubCntrC�fdI CiI(cll `1EC�hliL— Address IlGj Citysi!AV Lic# Phone# L/(/� <br />�_u <br />Area <br />GIS Coordinates: X , Y Townshlp Range Section <br />AMOUNT REMITTED <br />WORK TO BE PERFORMED: <br />Date <br />p NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) � DESTRUCTION (choose type below) <br />SOIL BORING <br />INVOICE <br /># VER -BORE, DIAMETER <br />-� <br />a WELL # ;trRESSURE GROUT <br />a `Other GROUT SPECIFICATIONS <br />COMMENTS: <br />C� <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING a HOLLOW STEM DIA. OF BOREHOLE a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br />a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL (] PVC a OTHER: <br />a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS a HOSE <br />a AIR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br />a OTHER: n OTHER APPROX. BORING DEPTH a BOLTED TRAFFIC BOX or Q STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />- �" <br />COMMENTS: tU1 l l �' I i 5' i T icki 1 l� � )(_3�" k AD l.ii , <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 Ordi es u e lations, and all applicable California State Laws. <br />Signed x �L/ TitlelCompany %'jl/ <br />Print Name / Date <br />DEPARTMENT USE ONLY <br />SITE MAP 1N UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted <br />Grout Inspection By_ <br />Destruction Insoectio <br />COMMENTS / CONDITIO <br />_Date Issued___ <br />AID# FAC# <br />Area <br />Final Inspection By <br />AMOUNT REMITTED <br />CHECK # REC'D <br />Date <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />Q14 <br />N=jrJV1AW= <br />ACCOUNTING ONLY: <br />AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # REC'D <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />C-57,_ WC__ -WAIVER_ C-57 Letter of Autho izotL9x to sign permitEncroachment doc__ <br />EHD 29-02-001 <br />6/22/04 <br />