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c^n Joaquin County <br />Enviroj,___tental Health DepartmentTE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd AWO 3 200'UNIT IV <br />\`.1 i -t t t7����y,,- Well Permit Application ENVIRO�Iti�'E - <br />REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PEPif`IMSERVICES <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 />A1'0 <br />II �7 I Assessors <br />WELL Location 222y ✓1'0h r ' K �. Cross Street ,� grt' ��, City Slcxl -c,, Zip cTS2pG Parcel# i & _', 13G C / <br />PROPERTY <br />Owner_ Address 222q dL� City--Sacc14c, Zip `51,Phone# (Zc `(L,Z - 7(oZl <br />C-57 Contractor�pp nuc, 6R.,Address 2 3� sl�a . �. City . o fel, Zip` SZ15 Lic#LR[)r Phone# (42`) qr 7-I0C� <br />Consultant/ Sub Cntr ,"TG F__ Address i S(nnw _ City Lic# (e snzZ_j Phone#(, - <br />GIS Coordinates: <br />V <br />Towns <br />Range Section <br />W056 TO BE PERFORMED: <br />FAC# ' <br />PE CODES <br />8'I EW WELL / BORING <br />(CPTt�( <br />HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />REC'D BY <br />0 -5 -OIL BORING # t�yv x . Cr 1 0 OVER -BORE. DIAMETER <br />350 l <br />0 WELL # <br />319, 00 <br />0 PRESSURE GROUT <br />0 *Other <br />GROUT SPECIFICATIONS <br />N <br />COMMENTS: <br />N <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />0 MONITORING <br />0 HOLLOW STEM <br />DIA. OF BOREHOLE 1.2 s' 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS/� - TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: Ij <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL 2L' TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE <br />R-USH POINT GP or CPT)GROUT SEAL PUMPED: 0 Yes g-Iiro (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />9_!_�_O_lL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS_ <br />0 OTHER: <br />0 OTHER <br />APPROX. BORING DEPTH 2C), 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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed <br />Print Name _ <br />Title/Company Sfnrlf C�Ierjoc,sf- <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 2 2 2 4 <br />WORK PLAN DATED--:/ 1 A our�i �I IS', 2oo S <br />Application Accepted By V 1 l[ oY', ' L. 1Y l e (A r .y Date Issued J R S" S Area i A 5 q <br />Grout Inspection By N),ciof.a1.. ML'�ar�h,!gj Date S. %i -65 Final Inspection By \.!,L�p{,C�L.M,,,(2rl-nc,.Pate X1.2-0 <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />FAC# ' <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE P ERVICE REQ INVOICE <br />350 l <br />3L8.00 <br />319, 00 <br />SR# 0 04 3414 y <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit doc <br />EHD 29-02-001 <br />6/22/04 <br />