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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 />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED D <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applicati 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 />ssessol <br />WELL Location 1705 co'" " Cjk 6 6 [vrk Cross Street ISy %4v{, City Zip Parcel# <br />S�Uc�(I 4 rs <br />tclh `lslu ' <br />Owner �J) Address _ _ Ity Zip Phone# <br />C-57 Contractor Sdh ,. T, T1� Address M. IZ4 CitywOOJ UKZip 9P -i (; Lic# �0 i3$ Phone# 30) (.4r- 14A <br />I <br />Consultant/ Sub CntrS6-u, A% LhyY�hw�h�1 Address 3330 ��+►iv�� Pk, 1( lir• City �v MlPym Lic# Phone#(gt�)yj �bii6 <br />S Q, X50 <br />GIS Coordinates:: 37 %4> -, Township I Al Range L E Section 5 - <br />WORK <br />WORK TO BE PERFORMED: <br />P,NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) B DESTRUCTION (choose type below) <br />0 SOIL BORINr- If 0 OVER -BORE. DIAMETER <br />WELL #, A1111., 0 PRESSURE GROUT <br />0 *Other I FWV I I GROUT SPECIFICATIONS <br />COMMENTS: _ 5i`2 <br />r <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS q <br />X MONITORING HOLLOW STEM DIA. OF BOREHOLE_J. � 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 1 _ <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SW 40 TYPE OF CASING: 0 STEEL kPVC BOTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 3 4 TREMIE TYPE TO BE USED: 0 AUGERS CHOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: )Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS CfAt(A� <br />0 OTHER: APPROX. BORING DEPTH ](BOLTED TRAFFIC BOX or B STOVE PIPE <br />CONDUCTOR CASING PROPOSED 1,0% _ (if YEAS, lis specifications in commept section) <br />• <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Orrrddiiin�anXx Rules and Regulations, and all applicable California State Laws. J L <br />Signed x `� � "` Title/Company pVbj Pc.J ��°lurjni , S�-+T,,�-' s EVti/'ra ti iMf(gk" <br />Print Name 41( CAVA b%AU ""j Date 3/1!lO -7 <br />SITE MAP IN UNIT IV FILE, ADDR <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By_ <br />Destruction Inspection B <br />COMMENTS / CONDITION <br />DEPARTMENT USE ONLY <br />Date <br />_Date Issued_ <br />nal Inspection By <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE IPLIT INVOICE <br />me <br />14V <br />S R# <br />C-57 ✓ WC= WAIVER_ C-57 Letter of Authorization to sign permit_ nc oc <br />EHD 29-02-001 79" e --5r <br />6/22/04 / _v`� Dom/, - / <br />