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San Joaquin County o <br />Environmental Health Department 26 SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />L <br />�' MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.o d� 6-2004 UNIT IV <br />Well Permit Application ENVIROVOENT <br />PER�11 / HERLTN <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUE $FRVI(;E5 <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />Q l / C Assessors <br />WELL Location 2 `ISS `- S P11ZAl f�l�! ��r Cross Street j ( t I City Zip Parcel# ` r-� C' / <br />PROPERTY /� / I 6 <br />Owner 'V�t�4f ox Rt fly;)SAddress 2�- Ltp%K Lj1j Ad F.City FtLg ,I,•)41e Zip 3J)C Phone# Fsyj So —/ 9Z:� <br />C-57 Contractor �t W !J�� II il,Address p-I%�C -VA-1 City15 le 4:41 h <br />ZipTS- i I Lic#%`ivV Phone ``� <br />1k '77 �"'z <br />Consultant / Sub CntrTAnw (lie Address 1 Y5 `i ? i�'� Winlcc;, Wi, City LY'7 Lic# Phone# Sj 1 JL 2 <br />GIS Coordinates: X Y Township S Range 2 Section ' <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) XDESTRUCTION (choose type below) }� <br />0 SOIL BORING # :$OVER -BORE. DIAMETERS <br />0 WELL # 0 PRESSURE GROUT <br />0 *Other / GROUT SPECIFICATIONS Nlk-L <br />COMMENTS: yD,�i�� ibL)4 Q►.cl sri��)t �tJc'_ T�t�n�/•3Y/ns k,e��s <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />!kMONITORING 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 />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <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 />0 SOIL BORING 0 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: <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 Or inances, Rules and Regulations, and all applicable California State Laws. <br />Signed x . l Title/Company Q' % -4V-LA <br />J •1� <br />Print Name VI ,i" Date Ls�.�!: L\oj <br />DEPARTMENT USE ONLY j <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By i • Date Issued Y130 ) b i Area 9 i' <br />Grout Inspection By J Date Final Ins ection By Date <br />Destruction Inspection By _ Date <br />COMMENTS / CONDITI <br />ACCOUNTING ONLY: AID# F <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE CER ST # <br />INVOICE <br />S6?- <br />1a 6 <br />$ (a b <br />t a-�1 <br />SR#o -311�-f 3 <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit Encroachment_ <br />EHD 29-02-001 <br />6/22/04 <br />