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San Joaquin County <br />Environmental Health Department SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd NhT IV <br />�I� Well Permit Application Zt46 AUG -3 W <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDSA <br />S julk Rt T� <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This ' i it n4$i Itance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental � ment. <br />Assessors <br />WELL Location 'LLSO Nowt_ D I&lol,c AVC Cross Street dt kve City 5}bckir,-A Zip ?5ZO3 Parcel# <br />PROPERTY 3 1I 1 <br />i-' <br />Owner Li!Mkav Address I ate ' k1<' ity Sf7x ojpj Zipj9701 Phone# 10-W' -Z75t) <br />C-57 Contractor MAKtjAC4Vif#om Add'resss &"37 56W Pet City ' Zip S&6Lic# G�� Phone#yf-`t'�7-101 <br />Consultant / Sub CntrAdMA �� _Cjed1*?iftfdP' Address 1111 5%,aw Rd City s 'l Lic# Phone# <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED: <br />�WEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) p DESTRUCTION (choose type below) <br />`SOIL BORING # 7 a OVER -BORE. DIAMETER <br />a WELL # a PRESSURE GROUT <br />a *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />a MONITORING a HOLLOW STEM DIA. OF BOREHOLE_LLL' 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: A_ <br />a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS M4 TYPE OF CASING: U STEEL D PVC D OTHER: _/V/l_ <br />a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br />a AIR SPARGE/ OZONE XTUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes )ICNo (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />J SOIL BORING a HAND AUGER GROUT SPECIFICATIONS Qcr-H.04A <br />a OTHER: a OTHER APPROX. BORING DEPTH 5' a BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED (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 <br />County Ordippces, F3Aes iifnd Regulap <br />Signed <br />Print <br />lication and that the work will be done in accordance with San Joaquin <br />and plicable California State L� <br />Title/Company (/// <br />Date — z- C <br />�- ,/ DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: A[d Sy �0 <br />WORK PLAN DATED: A " /1 ?/.1 19 d � <br />Application Accepted By ( 1 't i "L' Date Issued_ <br />Grout Inspection By Date 0 � Final Inspection By <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: Ll_c�. �: <br />"31I <br />6' <br />G <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />EST # INVOICE <br />3501 L3503 39 <br />� i <br />2�Z Z <br />��,'� <br />3 <br />SR# (off <br />r as <br />C-57_ WC -WAIVER— C-57 Letter"Of o"f cAut orizati to sign permit_ Enc tnent_dos-----� <br />EHD 29-02-001 r <br />6/22/04 <br />3 <br />0 <br />