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-an Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton,Q <br />(209) 468-3449 Fax: (209) 468-3433 Web: www _ �J <br />Well Permit Application 1006 <br />IJfIAI_ACCI IKMAPI F DFPMIT FYPIPF=Q i VFAP 9:Pr1M MATE IRAI IFrI <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the woi <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County <br />H <br />SITE <br />MITIGATION <br />Th <br />on is made in compliance with San <br />Assessors <br />WELL Location Zz?_`i VIcrtFheJ K�. Cross Street r4Sf. City Zip S Parcel# 6,3--I _b7 <br />PROPERTY 'f ii <br />Owner 01i ,'V JA un n �. Address 222`/ 11i7�� N o QJ - City S; k h�.� Zip `/�' a �, Phone# .1 — 7 (n 21 <br />C-57 Contractor I)r•ljjj!a V. Address 7gDG) tM rfi, .ASC City t�-E lir, Zip `fSt�31_ic#Phone# lljt��ly�-�t0�(C7 <br />Consultant / Sub Cntr A&E Address Ri'/ City Lic#(r80ZZ'/ Phone# <br />GIS Coordinates: X , Y , Townsh <br />WORK TO BE PERFORMED: <br />9-f EW WELL / BORING <br />0 SOIL BORING # _ <br />g-V/ELL # <br />0.Other <br />COMMENTS: <br />(CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />, <br />Range <br />Secti <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />B'MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE f'' 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS ` . I .. ` ')(I TYPE OF CASING: 0 STEEL e -P -VC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL �' TREMIE TYPE TO BE USED: H -AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: g -Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Ty{�,:, 1/19- <br />a <br />i90 OTHER: 0 OTHER APPROX. BORING DEPTH ?<•' ff-V61-TED 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 />—_i •> `I (ilea 6. -t[�.� <br />Title/Company <br />DEPARTMENT USE ONLY <br />5— <br />SITE MAP IN UNIT IV FILE, ADDRESS: 2_224 M a rill ey Road S1 -n a kho n CA <br />WORK PLAN DATED: February 17 2oh G <br />Application Accepted By dIG+oria L MafAr+neN Date Issued JU1y 2/,. LOOL Area 1469 <br />Grout Inspection By ViG.'-I'Ibr,'g1_ M&62k-}n!ft Date 8-1-04, Final Inspection ByDate 9-1-1)6_ <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: Sn 5 S M W - + t 0 gyp,+ <br />ACCOUNTING ONLY: <br />AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE P T/# <br />INVOICE <br />3 503 <br />2'14 <br />36 B, O <br />SR# <br />Q `7 59G <br />C-57 WC= WAIVER_ C-57 Letter of Authorization to sign permit_ oachment doc <br />EHD 29-02-001 <br />6/22/04 <br />