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San Joaquin County(�Cm <br />Environmental Health Department .R E, r (��' �\51TE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehAPR W ON <br />6 2005 UNIT IV <br />Well Permit Application ENVIROWENT HEALTH <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED EWT/SERVICES <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 />PE CODES <br />Joaquin County Development Title. Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />AMOUNT REMITTED <br />Assessors <br />WELL LocationU �(� �7�C 1 Cross Street <br />REC'D BY <br />NiJQFO City Zip Parcel# <br />P INVOICE <br />PROPERT '7 ��``9 <br />Owner I1(i �� (� I� Address PQ ; ZI Z � City 101& U �/, <br />tG Zips /V-Phone#�7<E'Z`�'1� � <br />9,00 <br />C-57 Contractor [A—e-,—I&IF 4rlllhAddress A/7Z, OM&-) (4 r'1L City 6u " ipA ZLic# �/ /SI( -Phone# '?*' &38 A,!j <br />Consultant / Sub Cntr / (8 Address 937 S&MV /�KIC� City Lic# GZ Phone# <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />M -NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) p DESTRUCTION (choose type below) <br />C� <br />0 SOIL BORING # 0 OVER -BORE, DIAMETER <br />WELL # ' . Xie' ' Z 1��. , ' 0 PRESSURE GROUT <br />-C <br />0 *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />— <br />all, <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />&MONITORING HOLLOW STEM DIA. OF BOREHOLE-L_)� 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: Z <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS `�4 OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />fTYPE <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED:a AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: Iryes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS��//°�iL'��%J <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH if�r I BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING P OPOSED. 1W (if YES, list specifications in comment section) <br />L <br />COMMENTS: z� Lw LV GL GF/ Y%7C 1FLv1� /�Z4<CC I�O�yI ! 1,� <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 Ordi nce Rules and Regulations_, and all applicable California State Laws. <br />Signed x ) Title/Company Ic-& <br />Print Name ��,r / Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 4040 EQSt Main, Street <br />WORK PLAN DATE\D:' MAV 20, 2-00+ <br />/� �7 Q <br />Application Accepted B �/ I r Q L. M C ) Date Issued / t 12/ X00 S Area S/ <br />Grout Inspection By ,(� Date i S— Final Inspection By i Date A�- <br />Destruction Inspection By D to <br />COMMENTS ICON DITIONS:=S 1IC1T' nn D Q roL)n WQ)-LY rnOYli 0,-,'n0 W �� S rVi JA/- lvt 2 INki-3 <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK* <br />REC'D BY <br />DATE <br />P INVOICE <br />3501 <br />9,00 <br />89.0 <br />SR# 0042078 <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit_ croachment d <br />EHD 29-02-001 <br />6/22/04 <br />