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San Joaquin County 'no WENE[4 <br />Environmental Health Department SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 JUL 1 5 2005MITIGATION <br />(209)468-')449 Fax: (209) 468-3433 Web: www.sjgov.offONMENT HEALTHUNIT IV <br />Well Permit Application 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. 27-0008 <br />Assessors <br />WELL Location 425 Z101" ieoa-A Cross Street Iv' .-city uG Zip 530 Parcel# <br />PROPERTY CC /� /�n� <br />Ownerlam& w rtt-SR&A6'" Address37l?0j.11IIi�� y �, r-40 Zipll�lOPhone# 1117-36� <br />C-57 Contractor Vitt;`5 Dr►llllno, Address G1�% 444 �Z CityV,�z�Zip�G ic# Phone#�o1' 823 318' 1�L <br />Consultant / Sub Cntr6FA TAAC, nn�� Address3531 +� w'City CC22.ffz Lic# 7ig Phpone#�ld�-3/e'�-�(95 <br />GIS Coordinates: X 'Y /V.1 Township ��4 SFlG U Kange 5 WGU 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 />WELL # I9�-2-Cp 10 :2-1 0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING I HOLLOW STEM DIA. OF BOREHOLE a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: o�-j1 <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSS�k`� 1UL"TYPE OF CASING: 0 STEEL j PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL '3-5' TREMIE TYPE TO BE USED: j AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 1 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 5'4 S.PilnJCM C- C4eKA -* S rr`1 rnC7� <br />0 OTHER: 0 OTHER_ APPROX. BORING DEPTH 1z6•� I BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED A) 0 (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, u e n, Regulatipns, and all applicable California State Laws. <br />Sianed x '�Title/Company <br />Print <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: ka <br />OfiC <br />Application Accepted By V Date Issued + - �2 7 - Area / 4 -4 <br />Grout Inspection By V;at'trr i Date - Final Inspection By r va ate 9 -2 -OS - <br />Destruction <br />i-O5— <br />Destruction Inspection By Date <br />COMMENTS/ CONDITIONS:�YL S �Q I f�, 1� l� r� Y G YY] DT2 1 +o Y . rLa <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT / SE EST # INVOICE <br />3501 <br />3G8.a <br />3 8 D <br />SR# Q�i4-3,27 <br />C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment oc <br />EHD 29-02-001 <br />6/22/04 <br />Z <br />su <br />