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"•ry San Joaquin County <br />Z ironmental Health Department SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br />"A68-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />` UNIT IV <br />ENVIRONWNT HEALTH Well Permit Application <br />PEPAIT/ jERW"iFUNDABLE 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 />1 1 i �, Assessors <br />WELL Location 3 1 y w ( e Cross Street �j' City t` `, Zip Parcel# <br />PROPERTY_ �s 3 - <br />Owner ��� S , r -c -Vo\ , r Address 3 Z 8o ln1 - L; rr e City �y+^ � c"', c � o'� Zip Phone# 2 l E <br />C-57 Contractor ��c2 1 �� : S Address ZZ C N - "S1 S-1 S1, <br />City Zip Lic# Phone# S 3 y <br />sulfa / Sub-C,trtr G— cam- Address -1 Citym\)�js 10 Lic# Phone# Z, c 1 S l -J 41 A `j <br />GIS Coordinates: X <br />Y Township Range Section <br />FACS <br />WORK TO BE PERFORMED: <br />PE CODES <br />FEE INFO <br />NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) p STRUCTION (choose type below) <br />CHECK # <br />a SOIL BORING # a OV BORE. DIAMETER <br />DATE <br />9 WELL # trv� <br />1 (Z a PRESSURE GROUT <br />35C ( <br />a 'Other <br />GROUT SPE CATIONS <br />d(S QYS <br />COMMENTS' <br />1�z�los' <br />SR# <br />TYPE OF WELL <br />INSTALLATION TYPE CONSTRUCTION '� 1 $ <br />SPECIFICATIONS , <br />VIir <br />MONITORING <br />HOLLOW STEM DIA OF BOREHOLE o MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: - <br />4 <br />EXTRACTION <br />AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING a STEEL 0 PVC a OTHER <br />r. <br />Q VAPOR <br />0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED a AUGERS a HOSE <br />` <br />a AIR SPARGE/ OZONE <br />p PUSH POINT (GP or CPT)GROUT SEAL PUMPED: p Yes p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING <br />p HAND AUGER GROUT SPECIFICATIONS <br />r <br />z <br />a OTHER:_n <br />OTHER APPROX BORING DEPTH a BOLTED TRAFFIC BOX or a STOVE PIPE <br />�. <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: <br />n <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 x_ Title/Company <br />Print Name Date r 3 1 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: C� / zd 1 0 <br />Application Accepted By _ Date Issued I l d S — Area Z t <br />Grout Inspection By 1�'�t,1,1, X41 Date 3 I i b `� Final Inspection By _-�iYV"l �!'� Date <br />Destruction Inspection By Date <br />COMMENTS ! CONDITIONS: <br />ACCOUNTING ONLY. <br />AIDS <br />FACS <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />��� <br />-PeRMIT tSERVICE QR1= UEST # <br />INVOICE <br />35C ( <br />gq oc� <br />d(S QYS <br />(,(,� <br />1�z�los' <br />SR# <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 />