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San Joaquin County_GM11% L <br />Environmental Health Department SITE lot <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV <br />Well Permit Application <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 9-1115.3 `jand the Standards of San Joaquin County Environmental Health Department. <br />WELL Location g5tg Coxo621 dub `'► y/Cross Street /A"r/SSi Assessors <br />City Zip � Parcel#i13j 710;2- <br />PROPERT� ' n �r / A <br />Owner �ldF % Address_7� %v-4 ttt Ayj City %Q. Zip 5��& Phone# lR2" 1QS� <br />C-57 Contractor 10b Address -19w `�fnuj-� 1 City Zip .i% �,g Lic#b71(ti }Phon D <br />Consultant / Sub Cntrr dy, i1tDF U1V-n1 _'f Address V S'{'�QW �d City��k-AM Lic#63222 g Phone - C 1(, - <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: o <br />>kNEW WELL/ BORING (CPT, GEOPROBE, HYDROPU NCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (ithoo ype below) <br />p SOIL BORING # 0 OVER -BORE. ��TER�p� <br />WELL # {Y) w — 5 p PRESSURE GROUT- - � <br />0 *Other GROUT SPECIFICATIONS / <br />61"V I1/10►1110 <br />. r <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />'MONITORING ;HOLLOW STEM DIA. OF BOREHOLE %U " 0 MULTIPLE CASINGS 0 MULTI-LRVL WELL'CASING DIA: _ Y <br />,EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSSC� TYPE OF CASING: 0 STEEL-iA�IZVC CQ OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 1 1 TREMIE TYPE TO BE USED: XAUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Poc and -1 Lff <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH 2`.> - BOLTED TRAFFIC BOX or 0 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 cegify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Or nances, Ryles and Regulations, and all applicable California State Laws. <br />Signed <br />MMI►F <br />SITE MAP IN UNIT IV FILE, AD <br />WORK PLAN DATED: <br />Application Accepted I <br />Grout Inspection By_ <br />Destruction Inspection <br />COMMENTS / CONDITIO <br />R <br />Title/Company 6111/ff3kfM? 4C4 SUt4;fk6,6- <br />Date <br />DEPARTMENT USE ONLY <br />/C_`� Date Issued <br />ate Final Inspection By. <br />Date <br />D Area <br />Date G <br />ACCOUNTING ONLY: AID# F <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / REQUEST # <br />INVOICE <br />36�• <br />233 <br />3 0� <br />sR# p���< <br />C-57 WC "-WAIVER C-57 Letter of Authorization to sign pirmit ✓Encroc men oc� <br />EHD 29-02-001 <br />6/22/04 <br />