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San Joaquin County ORIGINAI <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 UNIT IV <br />Well Permit Application 10NOV 10 pH Is 04 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DAT04&bY" i p <br />S�`i�! )G�r�t2�1'' Ol1k'3'1"1 <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work 4escryb�d, Thi�Nmibit4bHN t`+*Tpliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County =,-BE <br />'rflfi�AAssessors <br />22115110 <br />WELL Location '"v1UA Cross Street�Cityi Parcel#t -� <br />POROePERTY��; &� Address `'� �'T Cit ✓C -F 1 Zip/� Phone# � L bbe <br />C-57 Contractor lVl jf �C_���kddress G?`� -5A- L) � City J� 1 TSG ���$ip`��� Lic#46/ ) Phone# A1 <br />Consultant / Sub Cntr ' L� E Add <br />GIS Coordinates: <br />WORK TO BE PERFORMED: <br />,0,'NEW WELL / BORING <br />0 SOIL BORING #_ <br />0 WELL # <br />0 *Other <br />COMMENTS: <br />Y <br />Township <br />City Lic# Phone#, <br />(CPT, GEOP , HYDROPUNCH, HAND -AUGER, OTHER-) <br />TYPE OF WELL INSTALLATION TYPE <br />0 MONITORING 0 HOLLOW STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />CONSTRUCTION SPECIFICATIONS <br />Ra <br />Section <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />DIA. OF BOREHOLE ULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL L I- TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE'S <br />0 AIR SPARGE/ OZONE Iff-PUSH POINT (GP of CPT)GROUT SEAL PUMPED: 0 Yes ['No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />f9-�bIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER:_G OTHER APPROX. BORING DEPTH f Ir 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /><•) , 1 n _ 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 Ordinances, Rules and Regulations, and all applicable California State La S. <br />Signed x _L'�1��c',1�dt"_�( Title/Company 7) <br />Print Name` I (.d✓4 Z -L ff Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: q 9 3 A4 861d, <br />WORK PLAN DATED: l�I(LIY� 0 <br />20 . 2io G J' <br />Applicatibp Accepted By y i e -+,a a ;a L . Me- tay`T o L. Date Issued11 - 14 -n G Area I!q 5-9 <br />Grout Inspection By Li.41f 14d-YhDate 11 -.2q,04—Final Inspection By� ��r�iyj��[f ��l�p� Date 11 • <br />Destruction Inspection By Date I— <br />COMMENTS / CONDITIONS: <br />t� <br />ACCOUNTING ONLY: AID# <br />F <br />PE CODES FEE INFO AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PE UEST # INVOICE <br />35-63 .285-374.00 <br />SR# D0 97 <br />C-57 WC _ -WAIVER C-57 Letter of Authorization to sign permit :roachment doc�� <br />EHD 29-02-001 <br />6/22/04 <br />