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;.' ��i�Y San Joaquin County <br />ORIGINAL <br />nvironmental Health Department SITE <br />1'au%t Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br />(2 Q 449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV <br />Well Permit Application <br />et6R -b <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />�`� <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 n--'--1 Thio (ham t., 0-111A'1 -4 the Standards of San Joaquin County Environmental Health Department. <br />Assessors <br />WELL Location �0 0 l� - ross Street �R'���3� Zip 21 3G) Parcel# Q <br />PROPERTY �Y ,/ / /G���� � 33 O <br />Owner ("I T'1 wiI Address�(�//yv�' Cityt'v_Zip hone# n <br />C-57 Contractor f� /��i �- /-Dr'-; - Address /Zy f � �r`�' City /"'/Zip Phone# <br />Consultant /Sub Cntr Y- -� i1��i�LE ✓- Address -Zy� S C �y217FCity SY�it, Lic# Phone#2rl" Xlj/ 3,fT <br />GIS Coordinates: <br />Townsh <br />Range <br />Section <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />WELL # 4:L81�2--ice _ ,'y7 %%�%/'% /9� rZ% :-ia PRESSURE ROUT SPECIFICATIONS O <br />UT <br />'a.Other / , <br />COMMENTS: /1-1AJ' 1 <br />'Z <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS i <br />)PONITORING `� IOLLOW STEM DIA. OF BOREHOLE L� 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: __ <br />0 EXTRACTION /a AIR HAMMER/DRIVEN CASING THICKNESS 5�A Z 0 TYPE OF CASING: a STEEL `, `PVC a OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ':1 / TREMIE TYPE TO BE USED: UGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes �FA <br />No (NOTE: MAXIMUM FREE -LL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS % c�✓ "� - <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH. d dp 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTSA)/'7 <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 />sinned x ?' Title/Company <br />Print <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: � <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />DEPARTMENT USE ONLY <br />??D , <br />Date <br />-5 /57 zO <br />)ate Issued �^ <br />Inspection <br />swaSIME <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED CHECK # R C'D rY <br />DAT7 SERVICE REQU <br />INVOICE <br />AO <br />MVIJ <br />SR# Q 7i 3LLi <br />I <br />C-57_ WC— WAIVER_ C-57 Letter of Authorization to sign perm) <br />EHD 29-02-001 <br />6/22/04 <br />