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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.org/ehd <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />SITE <br />MITIGATION <br />UNIT IV <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 ocff San <br />/Joaquin <br />County Environmental Health Department. cr ) <br />3 5 5a WEL TY e Y � �V y �J / V 1�� � S3 g� Asses14 <br />WELL Loc//ation11ll ) /I JJ ►� 1 %%/Cros]s Street � City Zip (/� ParcelttPROP <br />OwnnerERTY -�t f D. `� FL L 1 1 V � Address ,14' W. f e"R y Meld, City�(I Zip�Ph�ne# - rJ � ^ ��- %1 <br />C-57 Contractor L- r��rr (�/I L1,(/ViY Address J _r,o <br />Address <br />City ip M;hone# 2SG- 3�6-5-s�0j <br />Consultant/ j <br />Consultant/ Sub Cntr Address590c) [,AKr City Qic#____1VA Phone# -16 " <br />L7n01Wf1d(i7I/LII <br />GIS Coordinates: X Vq, <br />Township _ Range Section <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING (�PT GEOP O E YDROPUNCH,�IAND-AUGER, OTHER') 0 DESTRUCTION (choose type below) <br />OIL BORING # 5B © �g 36 0 OVER -BORE. DIAMETER <br />0 WELL # 0 PRESSURE GROUT <br />0 *Other - GROUT SPECIFICATIONS <br />COMMENTS: 110� �T _2 1 1 t=may IW -,'ATP <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING HOLLOW STEM DIA. OF BOREHOLEf" 'r0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: +C�y- <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS_ TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL O'_ rD TREMIE TYPE TO BE USED: eUGERS -HOSE <br />0 AIR SPARGE/ OZONE XPUSH POINT (GP or CPT)GROUT SEAL PUMPED: Vesa 0 No (NOTE: MAXIMUM -M FREE -FALL DEPTH IS 30') <br />XSOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 7►' [i� (/rm /V <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH -7'EL-0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />/��n / J <br />CONDUCTOR CASING PROPOSED /� (if YES, list specifications in comment section) <br />COMMENTS: l/ r 1%� `'A '� c C'&? I r -D - tJ/' 1 Zw �esi 1 U 7 -yr/- UD <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 prep <br />County Ordinan es, R I and <br />Signed x � <br />Print N <br />this application and that the work will be done in accordance with San Joaquin <br />Mations, and all applicable California State Laws. <br />�y 1 tL Title/Companyo C-XFy S-Cimp 5� <br />Date A4W <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />i/J %i 1' 7 i <br />Application Accepted By d / 1 Area <br />Date Issue_ <br />Grout Inspection By Date D� Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />P UEST # INVOICE <br />s Ll <br />q <br />- � <br />SR#D� <br />C-57_ WC_ -WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br />EHD 29-02-001 <br />6/22/04 <br />