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0 <br />San Joaquin County R I G I Environmental Health Departmen NALjW,0- <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGNMIN <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd t"N yIT I <br />VIRu"���L��1T t�ALm <br />Well Permit Application I , <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 oaqu County Environmental Health Department. <br />/�� Assessort'ss,, <br />WELL Location l Q Cross Street City AL ZipCParcel#1 <br />PROPERTY S 1 j C <br />Owner \� �2r Address �7 I ��lX141) e�o'City _Zip 2 Phone# <br />C-57 Contracto jZDf) V � Address O/✓� CI /j4_ Ci G'Id, Zip(QLO L?� )Phone�/7�l(> _9_—A�j <br />Consultant / Sub Cntr o Address J!/frLJ City_.�ic# �,) Phone# V(67 <br />GIS Coordinates: <br />Y <br />Townshi <br />WORK TO BE PERFORMED: <br />j EW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') <br />0 SOIL BORING # <br />11NELL # 411111,0 <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE <br />MONITORING jv OLLOW STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CP1 <br />0 SOIL BORING 0 HAND AUGER <br />0 OTHER: 0 OTHER <br />COMMENTS: <br />0 <br />Range Section <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE. DIAMETER <br />0 PRESSURE GROUT <br />I GROUT SPECIFICATIONS s <br />CONSTRUCTION SPECIFICATIONS —� 1 <br />DIA. OF BOREHOLE L` 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS' i LIQ TYPE OF CASING: 0 STEEL Q\15VC 0 OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: kAUGERS 0 HOSE <br />GROUT SEAL PUMPED: 0 Yes ,(No (NOTE: MAfXIMWM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS cpq 16 p0 `f C�✓� <br />APPROX. BORING DEPTH BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <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 and egulations, and all applicable Californi State Laws. <br />Signed x Title/Company 6 t T9 6t— L•e�Lqt 5± L&tc <br />Print N <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted B .. / ( J Date Issued d -t- Area 3 I` <br />Grout Inspection By �. e l Date VIL tr 1 o ` Final Inspection By �' Date \ 0 L -t- ,I �— <br />Destruction Insoectio <br />COMMENTS / CONDITION <br />Date <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE ER UEST # <br />INVOICE <br />tr-3 <br />- <br />z,s..�� �Llll114, fl� <br />-oma <br />�4b3 3 <br />� C� <br />� SR#oo�C24_ <br />C-57 ✓ WC ✓WAIVER0\.4 C-57 Letter of Authorization to sign permitN�_nc c <br />EHD 29-02-001 <br />6/22/04 <br />