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" -in Joaquin County <br />Enviro.,mental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.Sigov.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 of San Joaquin County Environmental Health Department. <br />I <br />/�.� dc -6- r Assessor I <br />WELL LocationS157 L--,) - Ju5iy1C5S "'�'1' Cross Street J a city 1 �( ZipParcel# � <br />PROPER N (� <br />Owner Address /� City p Zip Phone# a,(q �/ 5' /t-? <br />C-57 Contractor Q 1 Address (1 �.� 1KP�✓IC'9 City $ Q Zip��L.icO D5y phonre# �/�-��U <br />Consultant / Sub Cntr <br />Pic <br />Address3� SViCsw City' iLic# 6]miL2i Phone�gI�b7 <br />GIS Coordinates: X 'Y Township Range Section <br />WORK TO BE PERFORMED: <br />PE CODES <br />p NEW WELL / BORING (CPT, GEOPROBE, HYDROPU NCH, HAND -AUGER, OTHER*) %,bESTRUCTION (choose type below) <br />AMOUNT REMITTED <br />0 SOIL BORING # XOVER-BORE. DIAMETER 1 1' <br />DATE QUEST # <br />0 WELL # 0 PRESSURE GROUT <br />350 <br />0 "Other GROUT SPECIFICATIONS <br />S <br />COMMENTS: <br />L6&SR#. S <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER:? <br />1�- <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />�S <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 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 application and that the work will be done in accordance with San Joaquin <br />County Ordinanc , Rules an Regulations, and all applicable California State Laws. <br />Signed x Title/Company Lne c� (,p—ok-Of <br />p � <br />Print Name�` k AA %il� 1l �/l�Rvl Date I � Iy� as <br />T <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />/ 2d <br />Application Accepted By Date Issued Area <br />Grout Inspection By4.ffDate inal Inspection By Date <br />Destruction Inspection By D e <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# F z� <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE QUEST # <br />INVOICE <br />350 <br />("o2, <br />5LVJ <br />L6&SR#. S <br />C-57 _'WC -WAIVER C-57 Letter of AutVi ti t sign permit n <br />EHD 29-02-001 <br />6/22/04 <br />