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San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />SITE <br />MITIGATION <br />UNIT IV <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 />/ !' ' Assessors <br />Df7 r y� <br />WELL Location �IbL� D� . i iNC.ylh S%�`ross Street W �fo 1►t� S�{✓e�City 1 Zip 9 2 © Parcel#_moi <br />PROPERTY►`;�} G-� <br />Owner //-� S-�tr1,&-'CNAddress_�45/vi �1(yo'laete 5f City S0t'1Z�l6,AjS <br />, Zip d2 Phone �37"- &?49 <br />C-57 Contractot$0)4OpPriI �iTN It Addres 2LW&— r(LeCit C Zip�Lic#7nS%J Phon�ttQrG 3(0g4!(�q <br />Consultant / Sub Cntr/ lJELcLtd 6CC FnU Address 840 75ky%J IN City.S��Lic# Q % Phone# -161-WO <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />HELL # , 0 PRESSURE GROUT <br />.10 *Or *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />)(MONITORING HOLLOW STEM DIA. OF BOREHOLE-ffL 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:Z <br />0EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSsem^ 40 TYPE OF CASING: 0 STEEL APVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL I7- T 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 yNQ lNOTF� MAXIMUM FREE -FALL DEPTH IS 30') <br />(it) <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS r t BV`f Q.�ctiQ�+ <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH '�,5 [ BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED�JT fl- (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 Ordinances, Rules and Regulations, and all applicable California State Laws. aa <br />Signed x I [__ /L Title/Compan�N\D <br />Print NameY\ N 1 ` 1M Date 7 1 1 tl <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, AD <br />�RESS: 33 S <br />WORK PLAN DATED: ���� <br />Application Accepted By !' Date Issued7 Q S AGrae <br />Grout Inspection By Date : 116 Final Inspection By Yrl e l () Date { (� <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# FAC# D 0 it f <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT / SERVICE REQ T# <br />INVOICE <br />0 <br />S R# 3,13 <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 />