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San Joaquin County RD)! <br />1 L Cc , � / E D <br />Environmental Health Department SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 0202`-'; MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgQy;org/ehd i i-.- . i-I':�LTH UNIT IV <br />� <br />AL Well Permit Application PERiV'i!/E_RVIGES <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 San Joaquin County Environmental Health Department. <br />AA � 1 r� I 1 ( Assessors <br />WELL Location 16 7/ /1/Ll d tr/, 14l i? S Cross Street L0 is City / �'1 G % t f Z� Zip �'f3j1, Parcel# .2(7 -U --oi1 <br />PROPTY.G'Qnni,Alatal;eTp1486 C•Louise JYlarlfG�� 9S33G <br />Owner I I i� Ir '� `� �' f 1 `Address / City � Zip!t�Phone / 55G <br />C-57 ContractorV✓P n <br />rC Address /.)C HO We 12cad Cityf144(4/n(ZZipo/gSS7)Lic#IKI� Phone#`WS� 3/3 06 <br />Consultant / Sub Cntr ('11M br I'L Address ,27 0 &/c, i rIS Sf City2 Lic# Phone#(707) Ct : Y- IfrSLy <br />GIS Coordinates: X :", / k I 1 5 5 't- , Y - ; L I � Z 1 _7'7 7 (k?, Township i '�> Range / Section 3 2_ <br />WORK TO BE PERFORMED: <br />D NEW WELL/ BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) DESTRUCTION (choose type below) <br />0 SOIL BORING # <br />and all applicable California State Lws./%% <br />Title/Compan <br />0 OVER -BORE. DIAMETER <br />d <br />0 WELL # <br />Date <br />(� O <br />;SPRESSURE GROUT <br />DEPARTMENT USE ONLY <br />0 *Other <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />GROUT SPECIFICATIONS <br />Ma n t - ,e c a <br />COMMENTS: <br />del 4-n((%7lYl Ot <br />3 LY1S1tc h'1L711T�I)?tl <br />WCl�S _ <br />Application Accepted By l-, <br />Date Issued <br />2 - 21 - 0 % <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />`R,MONITORING <br />0 HOLLOW STEM <br />DIA. OF BOREHOLE <br />0 MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION <br />D AIR HAMMER/DRIVEN <br />CASING THICKNESS <br />TYPE OF CASING: 0 STEEL D PVC 0 OTHER: <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE <br />0 PUSH POINT (GP or CPT)GROUT <br />SEAL PUMPED: 0 <br />Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS <br />0 OTHER: <br />0 OTHER <br />APPROX. BORING DEPTH <br />0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) ,, ^^ <br />COMMENTS: 0 <br />4 - <br />NOTE: <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 Ordinanc d Regons, <br />Signed x <br />and all applicable California State Lws./%% <br />Title/Compan <br />FEE INFO AMOUNT REMITTED <br />Print Name (fh� <br />DATE IT T # INVOICE <br />Date <br />(� O <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />10 i 1 N o rf In MO; n Si - <br />Ma n t - ,e c a <br />WORK PLAN DATED: I- e bII r <br />i a r �/ 1 S- Z D O L <br />Application Accepted By l-, <br />Date Issued <br />2 - 21 - 0 % <br />Area 145 q <br />Grout Inspection By <br />Date o? - - d Final Inspection By <br />Date 7 -2 9 �G <br />Destruction Inspection By <br />Date <br />COMMENTS / CONDITIONS: TQ s+r u r + <br />i nn of bA'VV - I M W - 2 rQ <br />n _MW - 2 <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE IT T # INVOICE <br />3502- <br />60.00 60.00 <br />SR# vo4 gaa <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit ncroachment doc_—Z <br />EHD 29-02-001 <br />6/22/04 <br />