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San Joaquin County <br />Environmental Health Department <br />600 E. Main Street, Stockton, CA 95202-3029 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED C" <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 />S 1 irk} ST/ 1 � p ^� Assessors <br />WELL LocatiorS,'(k? /1 11� k 4. m L" 101-1 1'. k Cross StreetCity.v c' (') Zip t � � 7 Parcel# <br />PROPERTY p p } c, <br />Owner�lyl�by/t�.G1i. ddress /�qSrt'��^Sory►l S City G1/tt Zip 103 t Phone# <br />C-57 ContractorE-wed., �U" I mac, Address lO [ (Lye— tL City k✓�t/'� Zip`i" � ' Lic# Phone#(1a5)3i3 716r)o <br />Consultant / Sub Cntr Q1�/V�fGi 1� s- S Atd1dress ( 't City Sl.H ff4'f"Xaic# Phone#i Yt; 1? ?'1 '` I yv)( <br />�XI3! , Y �) Z� 'C3 ( , Township_Range7i b <br />GIS Coordinates: X L� � Section <br />WORK TO BE PERFORMED: <br />Q►NEW WELL / BORING (CPT, GEQPRO6,E, YDROPUNCH, HAND -AUGER, OTHER*) p DESTRUCTION (choose type below) <br />0 SOIL BORING #f Z 0 OVER -BORE. DIAMETER <br />0 WELL # C�L�'J11PRESSURE GROUT <br />0 *Other `` GROUT SPECIFICATIONS <br />COMMENTS: 2 �f ,, t'h YG. Sl�V1 �I i 0(Ae c <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE -Z ,!� 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: ------ <br />D 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 T- C>* TREMIE TYPE TO BE USED: 0 AUGERS OSE <br />0 AIR SPARGE/ OZONEUSH POINT (GP or CPT)GROUT SEAL PUMPED:�i'es 0 No (NOTE: AXIMUM FREE -FALL DEPTH IS 30') <br />OIL BORING 0 HAND AUGER GROUT SPECIFICATIONS .�1Atty�1�rPB`'J�V` <br />PIS <br />/O OTHER: 0 OTHER APPROX. BORING DEPTH �2- D --L- 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED NO (if YES, list specifications in comment section) <br />COMMENTS: <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 />Signed x <br />- <br />eT`} <br />Print Name WX A. t� <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 />Title/Company l -le O� fit. <br />Date7—,/ Z-31/0 <br />DEPARTMENT USE ONLY <br />Date Final Inspection B& <br />Date <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE REQUES # <br />INVOICE <br />2,R0 <br />87' <br />03$-111 C+A <br />T-ro.a SR#19Q�'Ie,7-f <br />C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit ✓ Encro o W <br />EHD 29-02-001 web <br />6/22/04 <br />