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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.ov.org/ehd <br />PP s� <br />Well Permit Application 0i OCT 20 <br />PM 12:44 <br />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DA'Z`E' S;PEDI ! I ; C ; 'I f T Y <br />z�-T r5 i; "� ;'� k J <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the world p <br />bfj, pP #� ade in compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental �Oea(I D ick I. <br />WELL Location V3� YV. �JnQ�<-2� Assessors / <br />Cross Street City Zip awes J <br />PROPERTY' ` I jl_ p "& <br />Owner I Q� �� Address 1 I � - � Q`'��P� Cityc Zi ��/ hone# <br />����)) `,, y C°p`I �— hone#�z� � <br />C-57 Contractorwou War(,t y l II Address Z _ �2�X�,(3J ' _ I 'Cit rD�t t Zi ��Lic# W ' P 4 3� <br />Consultant /Sub Cntr n- � t(ddress III* ��.,k"114 City Lic# � I� 1 � Phone# g1(V-e_5 -Vf:�4 <br />GIS Coordinates: <br />Y , Townsh <br />Range Section <br />WORK TO BE PERFORMED: <br />p NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') p DESTRUCTION (choose type below) <br />a SOIL BORING # a OVER -BORE. DIAMETER <br />)KWELL #_,11�_W-i +i1c x4; r vel �-i3 a PRESSURE GROUT <br />o `Other 3 GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />a MONITORING k11OLLOW STEM DIA. OF BOREHOLE ,(% -' a MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: _ <br />EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNEA( 'iVC TYPE OF CASING: O STEEL B:�VC G OTHER: <br />0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL _�3 / TREMIE TYPE TO BE USED: AUGERS a HOSE <br />a AIR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes `(No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS Dnc, �'r _TV ZI CSL�cme,n " <br />a OTHER: 0 OTHER <br />COMMENTS: UOfF _r" ,`rte S Z� <br />)pgs -- bei ('3�d <br />NOTE: OFFSITE BORINGS <br />APPROX. BORING DEPTH ZIs' bu OL19 TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) til <br />&w�flxn 1=� Zs`bas Ser s,, I-- �.3` 4`,4!1Mt Z`-3rb <br />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 Ordina ces, Rules and Regulations, and all applicable California State Laws. t` <br />Signed x n o,, A /�--Title/Company \a / lA&I / Z C11, i e - <br />Print Name c��/�t `.�f2 N 6y 1� Date <br />�j DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: �OY'c3 T UJ, <br />WORK PLAN DATED: C3tX7 %, L6b1 <br />Z�� <br />Application Accepted <br />Grout Inspection By_ <br />Destruction Insoectio <br />COMMENTS/CO <br />Date <br />inal Inspection <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED CHECK # <br />REC'D BY <br />DATE PERMIT QUEST # INVOICE <br />SR #5yk <br />C-57,/ WC -/. -WAIVERC-57 Letter of Authorization to sign permit_ Encroac m oc /✓ <br />EHD 29-02-001 <br />6/22/04 <br />