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San Joaquin County <br />x2- MAR 0 5v><r <br />onmental Health Department <br />t30 ast Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />VIR0Nk T4 -jfP Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />PERMIT/SERVICES Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <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 />Assessors <br />WELL Location Z\ C -5 Cross Street r\ City ezv3k-00k zKN Zip c1S 2-Q`4 Parcel# \2- -S t' `%� `► <br />PROPERTY <br />Owner. CY\�r1K- `��r;nws Address -a-5 3-S �n_d City '24t oC�]carZip Phone* <br />C-57 Contractor Address 3wt City "`lVc#, +, S Phone# t\tio, X03 - I lb`1 <br />Consultant/ Sub Cntr P4 -C -N b t S -Q31- Address %oitl s� c\A P w S Lic# Phone# Q1Ike $5l CILy } 30� <br />d r ?� 142. <br />iL.A . S iso <br />GIS Coordinates:>x�T�: Jr•,+;�v-1 u. 32-10 Township Range Section <br />WORK TO BE PERFORMED: <br />PF/INEW WELL / BORING (CPT, OPROB `HYDROPUNCH, HAND -AUGER, OTHER*) p DESTRUCTION (choose type below) <br />SOIL BORING # a OVERBORE. DIAMETER <br />a WELL # 10!21 0 F I A AAM a PRESSURE GROUT <br />`Other GROUT SPECIFICATIONS <br />COMMENTS:_ I.SV -\ , SQ V S'4 - <br />�. 'S%.P, Sv-1 ".`i': S'v j y moo',\v2--Nc� <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />a MONITORING a HOLLOW STEM DIA. OF BOREHOLE �u a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br />a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS_ TYPE OF CASING: a STEEL a PVC a OTHER: IiN <br />VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL___ TREMIE TYPE TO BE USED: a AUGERS a HOSE <br />a AIR SPARGE/ OZONE ;ff PUSH POINT (GP r CPT)GROUT SEAL PUMPED: 0 Yes A[No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br />a OTHER: a OTHER APPROX. BORING DEPTH -I - ` a BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED (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, Rules and Regulations, and all applicable California State Laws. <br />Title/Company <br />Signed x _ r O �¢ SCS5 ASZ�A�\ (- <br />Print Name Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: okd 3 10, !0 <br />WORK PLAN DATED: <br />Application Accepted By_ <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIC <br />Date <br />-5% io & <br />Inspection <br />n <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT / SERVIC Q # <br />INVOICE <br />lbOF <br />3Lsv'-SR � 9 <br />C-57 V WC ✓ -WAIVER_ C-57 Letter of Authorization to sign permit Enc ent doc <br />EHD 29-02-001 <br />6/22/04 <br />