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San Joaquin County ORIGINAL <br />Environmental Health Department SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV <br />Well Permit Application <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 />W 429 W•(J� r►nz,r Swy l -1 �"" (� , a Parcel# <br />WELL Location Lam, Cross Street Ill�iiitnt tom, City �,_��� Zip 1� <br />PROP TY p <br />Owner Address 0 W. 'l 1�t�r Si.City_ it Zip I�L Phone#20- <br />C-57 Contractor _ T <br />s C _ kddress Pt03�l)K,EC CM_ City ZipC?5Wic#SCJ Phone#Gj6-b_V' I'l'0 <br />Consultant / Sub Cntr Pqg:� ' /JAAVDkt41i�(1�Address 1124H R413jC& WIUA City fk�&# �✓V Phone# y/& <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />EW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />0 SOIL BORING # <br />,WELL # 2 Al. ul <br />0 *Other <br />COMMENTS: ( d.e, 121 <br />p". q8 <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />1 <br />��S''jL1a t�+tlly ji �f, <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING HOLLOW STEM DIA. OF BOREHOLE ' � 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNES� TYPE OF CASING: 0 STEEL DKPVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 3 TREMIE TYPE TO BE USED: 0 AUGERS �iOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: TYe— p (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 1 <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH Z 7KBOLTED TRAFFIC BOX or 0 STOVE PIPE <br />i CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: w�r!� &= 35/ qd <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. A <br />//-- <br />Signed x L i J �7i I�,, / �,{ ✓ Title/Company �✓/ i -o e c <br />Print Name (iY l �/r / / "LfL / fi i� Date —2 <br />'3DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: b7j7_- &l/. <br />WORK PLAN DATED: • ZZ -OS <br />Application Accepted By <br />Issued T 5 Area — V - <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 />PERMIT/ SERVICE REQUEST # INVOICE <br />35011 <br />sq. <br />2-?3Be <br />� <br />e z <br />P -Do 32-1 <br />C-57_ WC ✓-WAIVER_ C-57 Letter of Authorization to sign permit v"' -Enc C m D <br />EHD 29-02-001 <br />6/22/04 <br />