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San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />alp <br />_ ►�k"-ffi <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />MAY MITGATION <br />NIT IV <br />Well Permit Application 'WRONME ._ <br />5 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERM!T/SE..9V!CES ' D <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 />(c Kv K". �,i "---"Y ) (k`, y: �-w" Assessors <br />WELL Location P5 -Li CE1Ay IL10 Cross Street ill City` C jGl\ -Zip'j,;,),o9 Parcel# Ia�JII�Y(-Ca- <br />PROPERIv '�^__ H�uI1 fives <br />Owner_ �k'N A"AA ,Addressp. (l, r'� /� /1 )�It^ I �11} t City Zip �r�3 t` Phone# Cjj / Li ia� <br />C-57 Contractor MkAVKFCA &I'"14SAs CitySttl\LIAV�Zip`1�1� Lic#LLC"�7Phone# I AL�11 <br />Consultant / Sub Cntr <br />GIS Coordinates: X <br />Address <br />Township Range <br />C# (' Phone# too <br />Section <br />WORK TO BE PERFORMED: <br />0 NEW WELL/ BORI (CPT, GE PROBE, HYDROPUNCH, HAND -AUGER, OTHER`) 0 DESTRUCTION (choose type below) <br />SOIL BORING 0 OVER -BORE. DIAMETER <br />0 WELL # 0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />COMMENTS: <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 `PUSH POINT (GP or CPI <br />`g SOIL BORING <br />0 HAND AUGER <br />0 OTHER:_0 <br />OTHER <br />COMMEN <br />A <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE I,.a'0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS Ad TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />DEPTH OF GROUT SEAL ,T j) " TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br />GROUT SEAL PUMPED: 0 Yes No (N TE: MAXIMUM FREE -FALL DEPTH IS 301) <br />GROUT SPECIFICATIONS PC- <br />APPROX. BORING DEPTH )A; A ty 0 OLTED 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:Qrdinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x (� �' . �� ��^`- Title/Company <br />i � C <br />Print Name�c f X ��� Date > /I-,- G� <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: LlyNQ----Uz70—!5r <br />Application Accepted <br />Grout Inspection By_ <br />Destruction Insoectio <br />COMMENTS / CONDITION <br />Date <br />Final Inspection By <br />00—D <br />Arel+ 61 �4W <br />. X-5-/ S <br />WAWL�ill <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />P ER # <br />INVOICE <br />3�0 <br />C-)2 <br />l ;4A <br />�1 <br />sR# Z, p j <br />C-57 V WC �/' -WAIVER_ C-57 Letter of Authorization to sign permit_ oachtrte 6ce5 <br />EHD 29-02-001 * 97c <br />6/22/04 ee <br />