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ORIGINAL <br />San Joaquin County <br />v <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 <br />UNIT IV <br />Well6.Application <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.�o Joaquin County Environmental Health Department. <br />essors <br />WELL LocatioQa (�'(' / //c�`I���� v'e Cross Street c �/ City �" ` � r ���ip Parcel# 15-3 2n r <br />PROP T <br />Owner v / <br />C-57 Contractor <br />Consultant / Sub Cntr <br />GIS Coordinates: X <br />ddres: LO a �[/��t� its et l?✓' Zip!,�one# <br />6,L/Address-777%S�- 'll%?Gi-j Citylt" 67Zip�hone#/�'/ <br />fJ1Z, Address City�Lic# Phone# -/ 7 �' <br />Y —12-l. 25s , Township Range Section (� � <br />WORK TO BE PERFORMED: <br />[] NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') XDESTRUCTION (choose type below) <br />[] SOIL BORING # [] OVER -BORE. DIAMETER �l <br />[J WELL # ORESSURE GROUT <br />[] `Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS I <br />,ff-MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE e 0 MULTIPLE CASINGS [] MULTI-LEVEL WELL CASING DIA: _z _ <br />0 EXTRACTION [] AIR HAMMER/DRIVEN CASING THICKNESS ` C;( l qty TYPE OF CASING: 0 STEEL , PVC 0 OTHER: <br />0 VAPOR [] MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS [] HOSE <br />[] AIR SPARGE/ OZONE [] PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes [] No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING (] HAND AUGER GROUT SPECIFICATIONS r_ . c /4 <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH ��C 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />11�� _ CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: MLO `-1 Is <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 .mac-= Title/Company <br />e <br />Print Name % i ! / fl,. /"i Date I <br />DEPARTMENT USE 9NLY Go� <br />SITE MAP IN UNIT IV FILE, ADDRESS: l� V N, ��- b <br />WORK PLAN DATED: <br />Application Accepted <br />Grout Inspection By_ <br />Destruction Inspectio <br />COMMENTS / CONDITION <br />Date Issued ''%�/ Q P Area <br />66 <br />Date Final Inspection By <br />Date <br />ate 7---1 S -d <br />ACCOUNTING ONLY AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PE EQUEST # <br />INVOICE <br />-73��y <br />W <br />�o,'" <br />r3 7-0 <br />f- SR )� �T I <br />C-57 ✓ WC ✓ -WAIVER_ C-57 Letter of Authorization to sign permit --TTMr-oachment doAC1- <br />EHD 29-02-001 <br />6/22/04 <br />