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San Joaquin County <br />nvironmental Health Department <br />'East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />209,) 468-3449 Fax: (209) 468-3433 Web: wvvw.sjgov.org/ehd <br />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <br />��- " ­ Well Permit Application / �J <br />ENVIROWE�t i N�/,I k r ' -(1 �TC <br />J��N�I2EFUNDABLE PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br />'F 7 <br />Application is herneh� IJI Rb \ oaquin 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, Cha ter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />AI\t * ! Assessors <br />WELL Location )AC) Cross Street City A-�VclL; Zip 'rJ,A�j4 Parcel#� <br />PROPERTY <br />Owner__ Address kM\ \),� , CP y -W y- City Kms&�-kxV, Zips L_ -%Phone# Z - -_2, `L <br />C-57 Contractor '�, QOA.14ht� !x(1111 r rAddress G tier :•� .?�_3 L Cily f ii_,.�/- SiTj Zip&i ) I Llc# 71 L'0 Iii Phone# 70\'7 7 �(—�-},3bD <br />nsultant / Sub Cntr cje0w'j OCA��Ckll C _� Address \C\ -4 City, '. L! � Lic# _Phone# ZC�1>'=72 2 - L{ uq <br />GIS Coordinates: X , Y <br />WORK TO BE PERFORMED: <br />D NEW WELL / BORING <br />D SOIL BORING # _ <br />D WELL # J <br />0 `Other_ <br />COMMENTS: <br />Township Range Section ` <br />O <br />E, HYDROPUNCH, HAND -AUGER, OTHER`) D DESTRUCTION (Choose type below) <br />D OVER -BORE. DIAMETER <br />D PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />t <br />c-, J <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />Q MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL D PVC D OTHER: <br />0 VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS D HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes D No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />D SOIL BORING D HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />_ � CONDUCTOR CASING PROPOSED _ (if YES, list specifications in comment section) <br />COMMENTS: fx-4- Cv ti�UC�n �r + �C� �( Vii'. CS�Lt_ i r <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />I hereby certify that 1 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 x Title/Company V Laza Len-4�ej <br />- <br />Print Name --S c _�_Date OS O -0 6 <br />DEPARTMENT USE <br />ONLY P <br />SITE MAP IN UNIT IV FILE, ADDRESS: 0�0 /U,2f.►f` lly� <br />WORK PLAN DATED: //- 3a-05" ' <br />Application Accepted By_ Date Issued <br />Grout Inspection By Date_ 04 Final Inspection I <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />'99 <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE R T # <br />INVOICE <br />iso <br />2 <br />�Jlo�.�'� <br />6- <br />SR# C)o <br />C-57 ✓ WC_✓ -WAIVER_ C-57 Letter of Authorization to sign permit N ncr4- <br />-/_M <br />EHD 29-02-001 ((� <br />6x2/04 <br />