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San Joaquin <br />ORIGINAL <br />County <br />FEE INFO <br />Environmental Health Department <br />SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />UNIT IV <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />, rr <br />O 1 V <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. <br />3 Assessors <br />WELL Location 2 \Q <br />C-a"v.�r�irvg, Cross Street � �w+1� �,r� City �`c4c_t�r..�ccrr� Zip � $ Li_4A Parcel# 1 Z-� L`2 0 �,' 1 <br />C AV_—N3 <br />PROPERTY <br />Owner .^^c"r'C.. `_�{1 r , � Address �!S S y W h 1 V -v. ,wn City ip ;,A Phone# <br />C-57 Contractor C`T7c.rTD E Address ��jly-F�.LLippl J /&one' <br />��c.l� f` <br />Consultant /Sub Cntr Address -1 v o lcQ City Lic# Phone# \til <br />GIS Coordinates: X 'Y Township Range Section <br />WORK TO BE PERFORMED: <br />pr\NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # "e- A4 e, 0 OVER -BORE. DIAMETER <br />;KWELL #y-,�/� 1Cha 0 PRESSURE GROUT <br />0.Other C G ��Irtwt �-^ J / GROUT SPECIFICATIONS <br />COMMENTS: '\�n�z wz �\ S� A - �c �� i - 2e r \ <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS n — <br />MONITORING IKHOLLOW STEM DIA. OF BOREHOLE 1NULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL '(PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Sf—ZT TREMIE TYPE TO BE USED: AUGERS a HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH -2,1', 50 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) C <br />COMMENTS: 0, S ~ <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 x Title/Company llry \ Sc ,�\ ��} ?_�&(- <br />Print Name TCY�.n c. M�� Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: a <br />WORK PLAN DATED: CO -5-0 <br />Application Accepted By Date Issue <br />Grout Inspection By Ifte Final Inspection <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE PERMIT /SERVICE Q <br />INVOICE <br />�j 50 <br />iii il/l/fR# <br />C -57V WC ✓ -WAIVER_ C-57 Letter of Authorization to sign permit �`�R>rreachuiep#� <br />EHD 29-02-001 / <br />6/22/01 <br />