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N San Joaquin County <br />-..,z Environmental Health Department �uSITE <br />{ 600 E. Main Street, Stockton, CA 95202-3029 t -C,�MITIGATION <br />' " (209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd" � � <br />NIT IV <br />Well Permit Application rs{�'1R0�,1ivjEN'f HEAL <br />pP pFRN1iT/SEER/ <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. and the Standards of San Joaquin County Environmental Health Department. <br />Assessors <br />WELL Location Kc�/i.-l.L� 5 lJt-1 e(,� Cross Street City Zip Parcel# <br />r g -2to' <br />��Wone# 67 (.tom <br />Consultant/ Sub Cntr Address kt City N Lic# b� Phone#. <br />GIS Coordinates: <br />WORK TO BE PERFORMED: <br />,OEW WELL / BORING <br />0 SOIL BORING # _ <br />0 WELL # <br />0.Other <br />COMMENTS: <br />Y <br />Township <br />(CPT OPROBE HYDROPUNCH, HAND -AUGER, OTHER*) <br />TYPE OF WELL <br />INSTALLATION TYPE <br />0 MONITORING <br />0 HOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE/ OZONE �USH POINT GP r CPI <br />OIL BORING <br />0 HAND AUGER <br />0 OTHER: <br />I7 OTHER <br />COMMENTS: <br />- X 1 1 %lJl��/i A <br />Section <br />/( <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />CONSTRUCTION SPECIFIC T S <br />DIA. OF BOREHOLEY_t�bqaTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS TYPIa OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />DEPTH OF GROUT SEALTREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: XIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS Leri► <br />APPROX. BORING DEPTH 3 CT BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <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 Ordirlances, Rules anq Regulations, and all applicable California State Laws. <br />Signed <br />Print <br />Title/Companyccay <br />A <br />MN <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS:�� <br />WORK PLAN DATED: AvauxtqR am,al Jv1 <br />Application Accepted Byy/ & ipx i aL L, M eA14 e±n Date Issued '71 ?V / b % Area 4.5 9 <br />Grout Inspection By �l (,+by A M0_ (?4 Ir'I�Date 8 - /L. Final Inspection By b 7 <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: f " b2 Are_R_LL.4 <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE IT / SER UEST # <br />INVOICE <br />3Sa 3 <br />8 a <br />394. ao <br />`eSN- <br />-e-� <br />'71-Zo o7 1 S R # 00 5'_ - <br />C-57_ WC_ -WAIVER_ C-57 Letter of Authorization to sign perm) ncroachment doc_ <br />EHD 29-02-001 web <br />6/22/04 <br />