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San Joaquin County -ORIGINAL <br />Environmental Health Department(� f �` SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202H E cc E vl MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.Sigov.org/ehd L � _ 9 2005 UNIT IV <br />Well Permit Application <br />ENVIRONMENT HEALTH <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 071' '' "' ICES <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 />J / 1 / Assessors <br />WELL Location 2575- (o.' " GLS Cross Street P t, �� City S rCC' Lf&- _Zip9 `J2o Parcel#) 2 3- 02v -/ Z <br />PROPERTY <br />Owner_ ��v, C� o vet Address -51V -1 y9/1g4o utj le, 1, iCity- 1,1„w+ '1 g41hone#_ A-/ <br />C-57 Contractor L/Ir-l!!5 rAddrt ss 44 City /".,4,,e&Zip YS ic# y�Phone# 9��-313-Sgvo <br />� 9SY7 G <br />Consultant / Sub Cntr�,. ,�/„� �n✓Y �on/6C� Address 170 P*ree � City an Lic# Phone# 7o-7-7,33-2367 <br />GIS Coordinates: X <br />Township <br />Range <br />Secti <br />WORK TO BE PERFORMED: <br />AdNEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) p DESTRUCTION (choose type below) <br />[] SOIL BORING # 0 OVER -BORE. DIAMETER <br />W/VELL # MV- g� _ /`' V -/G. N V -/?, n 0 PRESSURE GROUT <br />^[]°Other �� —� GROUT SPECIFICATIONS <br />OR <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS !/ <br />MONITORING HOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS °(O TYPE OF CASING: 0 STEEL XPVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 't-10 / TREMIE TYPE TO BE USED: $AUGERP10 [� O E <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes ANo (NOTE: MAXIMUM/ FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS loci l" Z/ZX �r+•C•-T <br />0 OTHER:_0 OTHER APPROX. BORING DEPTHZ— BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED 0 (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,j4ul9f nd Relations, and all applicable California State Laws. <br />Signed <br />Print <br />CV, <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: 00--3-0 <br />Application Accepted By_ <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />Title/Company��G/!r �pp./ (Xre� •%f� <br />DEPARTMENT USE ONLY <br />Date <br />Date Issued A1 —/-I- —e' �Area �6�5 <br />1 Inspection By COM _ ©ate /— <br />ACCOUNTING ONLY: <br />AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />T # <br />INVOICE <br />-35o'l <br />Alm, <br />�' <br />�oZZo <br />��- <br />SR# OD Si <br />C-57 / WC ✓-WAIVER <br />EHD 29-02-001 <br />6/22/04 <br />C-57 Letter of Authori tion to sign permit D -Encroachment doc <br />„ <br />