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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 />/I / W Assessors <br />/ <br />WELL Location 06 %buc �, I t n a,hI �kross Street {rW ��U �S //�1!%�City' Zip � � 0 Parcel# N <br />PROPERTY 2 �ql��-o�� <br />ff � <br />Owner-C4hfQTSfUL&z%LN Address14�dl �lC1U✓aC�C Sf City S�7N Zip K202 Phone# 937— Ps?49 <br />C-57 Contractor ii" JQ� E&IL/ Address S' % S �c City�f %- Zip 6 �S� Lic# to [wZ1%Phone# ¢(� %—/006 <br />Consultant/ Sub Cntr�Va,,1�6CV e.,,Cd Address 84 7,Sk(.yn Pd City.S�Lic#69()Phone# 4{07— <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 />OIL BORING # 0 OVER -BORE. DIAMETER <br />FEE INFO <br />0 WELL # 0 PRESSURE GROUT <br />CHECK # <br />0 *Other GROUT SPECIFICATIONS <br />DATE PERMIT / S UEST # INVOICE <br />COMMENTS: <br />�Q <br />3� Z <br />A2-t4q3 <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE_?_f 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: hJ <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 ";, V b V -Q TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 4rNo (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER:_0 OTHER APPROX, BORING DEPTH 5 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />a <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 and all applicable California State Laws. <br />RRegulations, <br />Signed x�l /o— y `[_ X—SLA Title/Company <br />Print Name_ V'\ VA, kCo,C„ Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADPRESS: -S <br />WORK PLAN DATED: Y/ O S <br />Application Accepted By e -7 S <br />/' Date Issued Area / <br />Grout Inspection By �1,titi�� � — Date 2 S C Final Inspection By r Date Q TO <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT / S UEST # INVOICE <br />u <br />3� Z <br />A2-t4q3 <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 />