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San Joaquin County <br />Environmental Health Department SITE <br />304 Fast Weber Avenue, 3rd Floor. Stockton, CA 95202 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: wsvw.sjgov.org/ehd -r IV <br />Well Permit ApplicationOG , Alw - <br />NON-RGFUNDABLG 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. 212 1 oo c F <br />+ r_ Assascors <br />WELL Loeation �� %YG�� Cross Street Y City Zip��Parcel# <br />PROPS s3 t—, p� y <br />Owner�rl��f iCdi�Si"O'r/�yl. ,l,Addres / r CI ZI G� ?�7PnaneYr a <br />C-67 Contractor t)/ P/ S %ji/l iWl Addressf? f?? 4w /I Ciiyls_ pJ�! �/LLicg 0 Phone#7_0Z 9ZF- <br />Consultant I Sub Cntr <br />GIS Coordinates: X <br />Y <br />Township <br />CityL_.iJlo Lic#2Z,�3Phone# .1.��� ,?Z-00? <br />Range <br />Section <br />WORK TO BE PERFORMED: <br />g NEW WELL l BORING (GPT, GEOPRO BE, HYDROPUNCH, HAND -AUGER, OTHER") Q DESTRUCTION (choose type below) <br />SOIL DO N # OVER GORE DIAMETER <br />WELL # �� Ce Q PRESSURE GROUT <br />d'Other GROUT SPECIFICATIONS <br />COMMENTS: _ <br />TYPE OF WELL INSTALLATION -TYPE CO.NSTIRUCTION SP_ CtFICATj_ONS 1p <br />[ MONITORING I HOLLOW STEM DIA. OF BOREHOL L <br />Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: ___ <br />A EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESSd TYPE OF CASING: p STEEL I PVC Q OTHER: <br />o VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL_ � - I KLMIL I YHt I U BE U61=U: III AUGEKS Q HUSE <br />Q AIR SPARGE/ OZONE Q PUSH POINT (GP or CPT)GROUT SEAL PUMPED; Q Yes III No (NOTE: MAXIMUM /FREE -FALL DEPTH IS 301) <br />Q SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 579 &,Y�mfP��dn r! AGI LrrUI rWl h� <br />Q OTHER: D OTHER APPROX BORING DEPTH P BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED o (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 applicatinn anti that the work will be don* in accordance with San Joaquin <br />County Or finances, RI II Regr<Ilations, and all applicable California State Laws. <br />Signed x rC tl t►— �dd TitlelCompanV i 1� ti 1, _ 1A <br />Print Name Date <br />DEPARTMENT USE ONLY / <br />SITE MAP IN UNIT IV FILE, ADDRESS: 4.2 6- Vel. Lay -<J, RJ <br />WORK PI -AN n.ATED: <br />Application Accepted By Y i c t y c L 1 e 6&,r- Date IFsued 1 19` Area 1-4 5q <br />Grout Inspection By u i 6ho r,'& Me.Carfaf:! ,Dale _2 Flnat Inspection 6y 0 7 <br />Destruction Inspection By Date <br />COMMENTS I CONDITIONS: <br />ACCOUNTING ONLY-. I AID# <br />FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # Rl=G"p DY I DATE 3T # INVOICE <br />3501 °a i5A� <br />3 .�s5,ov t� �5 sR# <br />384.95 OC49 7-7 8 <br />C-57__ WC --WAIVER_ C-57 letter of Authorization to sign permit l=ncr�achment do,.-- <br />129-02,001 <br />og <br />F,.I'ID29-02.001 <br />6/22/04 <br />