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San Joaquin County <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.org2@50 A110 39 N 9:LMIT IV <br />SITE <br />Well Permit Application <br />SA F11 J0ilui 1 cauPIYY <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSU D,-`NVIRONMENTA L <br />--LTH DVP'yR-1`1E <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is mace in compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />WELL Location LC L Tr Assessors <br />if �t�i ty Cross Street O 1*4 W'V City '&001 Zip'IS 3;0 Parcel#_ <br />PROPERTY f _ <br />Owner `t�ti, (mit .gyp Address S' ,,4�ivt City %? Zipg 31 Phone# <br />C-57 Contractor Cct��[�(� Address_ A%'34 Cixt: Clr,il,— jCityF`cv1Ch/r�Zi{f�ZLic# 70-4-L Phone# 6't�>����6`� <br />Consultant / Sub Cntr jl=l!% Address i7rckGr��iZarJ1 Cit F6'hCk) Lic# S <br />City �rf9 Phone# ff6 L-c� <br />GIS Coordinates: <br />Township <br />WORK TO BE PERFORMED: <br />"NEW WELL/ BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER`) <br />0 SOIL BORING # <br />jj'VVELL # Ilkt�ti t t <br />D�Other <br />Range Section <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />COMMENTS: G <br />_- L_ <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />a <br />'MONITORING HOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 7 <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL iZVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL j TREMIE TYPE TO BE USED:AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes Q4lo (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS /l&A CC W2-' <br />0 OTHER: 0 OTHER APPROX. BORING DEPTHtf� A I %BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED AJC (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. <br />Signed <br />Print <br />Title/Company Stnft- [,"'i) c^ c 154 / SE( ')Q <br />Date U10 S c <br />7 T <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 15 ( OCA it ti'0 <br />WORK PLAN DATED: 1-5-05 <br />Applicatipn AFepted By U x Date Issued ` (t� 163 Area C <br />Grou4nspection By - Da / u Final Inspection By Date C�� <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: VOfI ) )orA '02' �r&' Yt%� At �"� 3 Graj <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />r <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIrTSERVIC€-REQUES.T- INVOICE <br />°I <br />-�3k3 <br />9i <br />I 4300 <br />X30 ! �3 <br />SR# L13 9 6 s <br />xm <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 />