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San Joaquin County F� — IE NgPSITE <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/elHAR . O 2007 <br />UNIT IV <br />Well Permit Application ENVIRONMENT hEAl1H <br />PERMIT/SERVICES <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 />ViVionj vo9cr4'c/orrole7'Y"Y AdX09CeAlr Assessor <br />WELL Location TD SLd Sr de of 1-4 16-AAnt! Cross Street Yokrw+,TC City MdAITL'CR Zip 9S39d Parcel#_cz I q 3 3 O Z <br />PROPERTY 57rr-r-r &?Art/7MQjCG9(5eQA70leHe4/+?AP! <br />Owner LWi6 wJ &-,{rG /W IyeAd Address/foo tj /qSSr. rns*_City Qih�Zip l7 Phone# (9'e 5 y&4_x.563 <br />EK9i.oAe7/o.o lGeae'rvrCEY,Sn/G. <br />C-57 Contractor Address /33r9ua. City5AW-'j9E_ip 75 Lic#YZy23E Phone#(Yom) Z$0-6822 <br />Consultant/Sub CntrRMMdTeciAT 5 Address f6yo/r/oAdUVtsrAOr. City Sae ee,r• Lic#Rek3S76Phone#(2e4) t9S-6211r <br />GIS Coordinates: X , Y Townshi <br />444r.Todo- 37.79tt p %'2S Range %E Section ) <br />WORK TO BE PERFORMED:s ys'-ttr. ZI69! <br />G <br />0 NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') ,'DESTRUCTION (choose type below <br />0 SOIL BORING # JKOVER-BORE. DIAMETER /Qb& IZI <br />0 WELL # 0 PRESSURE GROUT <br />0.Other GROUT SPECIFICATIONS <br />COMMENTS: tJf CA t- (feIA&,*Wt 101AQ) <br />'h <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />ACCOUNTING ONLY: AID# <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />FEE INFO <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />CHECK # <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />DATE PERMIT/ ERVI EST # INVOICE <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br />3sr7- <br />3 so 3 <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />20 Ate; , C)6� <br />CONDUCTOR CASING PROPOSED (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 Ord' antes, Rules and Regulations, and all applicable California State Laws. <br />Signed x ,fr <br />Title/Company Ah- 184 t ^jam zb r s Z t�j 145SAS <br />cIftu` <br />] <br />Print Name IGMgge— /V Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: ISI t1/� r t^ .� �- , jV,ot k Ar[e-. . <br />WORK PLAN DATED: <br />Application Accepted By Date Issued_ 3 /Z ZS"�O Area <br />Grout Inspection By LA�KAAAe Date Final Inspection By j jj�� Date 2 <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />C-57_ WC_ -WAIVER_ C-57 Letter of Authorization to sign permit_ oc/ <br />EHD 29-02-001 <br />6/22/04 <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT/ ERVI EST # INVOICE <br />3sr7- <br />3 so 3 <br />20 Ate; , C)6� <br />y£f�o $R <br />g d SO 10 1 <br />C-57_ WC_ -WAIVER_ C-57 Letter of Authorization to sign permit_ oc/ <br />EHD 29-02-001 <br />6/22/04 <br />