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San Joaquin County SITE <br />Environmental Health Department <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 />ication is <br />Application is hereby Development Title, Joaquin County <br />911 5f3rand thelt to construct Standard of San/or inst Joaqu nl the work described. This County Environmental Health IDepartmentmade in compliance with San <br />Joaquin County De p Assessors <br />7 ll D, c,}pc,�tip,n Zip RSZ03 Parcel# 21030 D <br />WELL Location 7 �� , Alavj Drwc. Cross Street 1r1�u�'l,a� 4 City <br />�aPRoP-7 t�n�► �^�3 0 PAY INb L P <br />PROPERTY }6 groa�wa,l City*�jL-14 .A�Q Zipj58,( Phone# <br />OwnerLMR PE,ill„Ii n� COMM Qau Address y Phone#9�'66g�Z'l2y <br />C-57 ContractorRSL Dri�`tALt AddressZ20 N. Ea4� 5fr66� CityW1k19 4 Zipj!9T46Li��2 <br />_ eI, _' SOj1:,Licm $UII39 Phone#�i���23�-Z�pO <br />1 AddresS 5� %iyll'Qak,S i�-�'Y City <br />Consultant / Sub Cntr&r+il 1�C f rIC <br />o r �� ° r 0�� Township / ,- Range ��E Section <br />GIS Coordinates: X 3j S-4 �0 Y `21 XU 3 P <br />WORK TO BE PERFORMED: c DESTRUCTION (choose type below) <br />XNEW WELL 1 BP.I <br />ONG (CPT, GE0PR0BE, HYDROPUNCH, HAND AUGER, OTHER-) a0 OVER -BORE. DIAMETER <br />0 SOIL BORINQ t 0 PRESSURE GROUT <br />VRNELL # –'rF 7juP I7� GROUT SPECIFICATIONS <br />0 *Other <br />COMMENTS: <br />.TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />Q WELL CASING DIA: <br />MONITORING HOLLOW STEM DIA. OF BOREHOLE S 0 MULTIPLE CASINGS 0 MULTI-LEVEL _Z <br />Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS SC6 . 0 TYPE OF CASING: 9 STEEL eVC Q OTHER: <br />Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL 30�— TREMIE TYPE TO BE USED: j�AUGERS HOSE <br />Q <br />Q TE: MAXIMUM FREE -FALL DEIS 30') <br />AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: Q Yes No (NO w4r <br />Q SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONSAI9 1 r4Ia^4 C`""` e LIED TRAFFIC BOX, or Q STOVE PIPE <br />Q OTHER: -0 OTHER_ APPROX. BORING DEPTH ZS <br />_ (if YES, list specifications in comment section) <br />CONDUCTOR CASING PROPOSED A/0 <br />COMMENTS: <br />/ACCESS AGRFORINSPECTIONS. N ROACEIMENT PERMITS. <br />MOTE: OFFSITE BORINGS REQUIRE <br />48 WORKING HOURS NOTICE REQUIRED <br />I hereby certify that I have prepared this application and that the work will be done in accordance with <br />County Ordi%nce,R.ulee and Regulations, and all applicable California State Laws. <br />�f G[A11415'+ <br />ry (�G^^" Title/Company task Ma-A0,�1tr/Sba. <br />Signed x /V <br />(' Date 0 <br />Print Name ./Ol v' a � <br />DEPARTMENT USE ONLY <br />San Joaquin <br />Teat )At . <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: 1&206 <br />Date Issued �T _Area yT_ <br />Application Accepted By g:t Date <br />Grout Inspection By Date Final Inspection By <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: w k <br />ACCOUNTING ONLY: AID# TFAC#PE CODES FEEINFO AMOUNT REMITTED CHECK# DATEkINVOICE <br />�V, 7 A 0'3 Z /11 <br />C-57 =_ WCWAIVER_ C-57 Letter of Authorization to sign permit_ Encr <br />EHD 29-02-001 <br />6/22/04 <br />