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fan Joaquin County <br />Envir.,..mental Health Department SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 REU <br />,`' ' MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd NIT IV <br />Well Permit Application <br />mm I'" <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED FPJ\If`'it.)�t��C r IT HEALTH <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is madelKcOmpliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />ypp Assessors <br />WELL Location 722y 6��ta FG. Cross Street L1;.-1: City Zip -1SZC`l- Parcel#_1C _z 1 <c' �' l <br />PROPERTY <br />Owner IVA4e4 �z Address 222c( r�U�{(a-, �. City LL, J, L,, Zip 1:;,2 Phone#�z< ;'((�Z -/( 2 <br />C-57 Contractor A� E / F v cooa.L Address 1, 3'Y �-L, o iZE� City ip gsZls Lic# L&SL�ZZ' Phone# 1/6 1 CC G <br />Consultant / Sub Cntr . d n�r2O (-er,Eo,�-rm",4) Address 3"1 0. !2 City `>t�c� f Li c# 'CMZ o e ., - t c <br />GIS Coordinates: X Y Township Range <br />_ URIONA1 <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING <br />SOIL BORING # _ <br />0 WELL # <br />0 'Other <br />(CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE. DIAMETER c J <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />COMMENTS: Osc, o s)1< lxI,,NG,--- <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 1 2`-," 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _• <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS IL- TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY ,,��-- DEPTH OF GROUT SEAL l ` TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE'PUSH POINTI(GPlor CPT)GROUT SEAL PUMPED: 0 Yes ,gNo (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />`B]SOIL BORING 0 HAND AUGERS GROUT SPECIFICATIONS 1/11 Pori lA t� C2Me� <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH `I'! ` 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED ��U (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 <br />Title/Companyo <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 222 4 Man 4 h e v -Road <br />WORK PLAN DATED: reb ru a r W 21. 20o7 <br />Application Accepted By V ; a*6V ; 4L ). _ m e -L4 rblfL, Date Issued r' -25- - d 7 Area <br />Grout Inspection By V;,ta,r'EL L, % e-&4r'h1GG, Date ']- 13-67 Final Inspection By . &trc / A 1. M,,444 ate 7- /3-07 <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: i/(jri in l„t7� �113 /0 <br />ACCOUNTING ONLY: <br />AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT QUEST # <br />INVOICE <br />3svl <br />�q <br />89. <br />as7i0 <br />SR# oD,So 74 <br />11 <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit "-Encroachment doc <br />EHD 29-02-001 <br />6/22/04 <br />