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San Joaquin County <br />Environmental Health Department SITE <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 and the Standards of San Joaquin County Environmental Health Department. <br />WELL Location 72 C_ ((�'Li Cross Street ('C'C Ci J , Assessors <br />tY Zip %S� Parcel# <br />PROPERTY tfK ��VOwnef -4t hl..�dAA / <br />u i� <br />C-57 <br />Cons <br />GIS Goorainates: <br /># kL31Y-y3o.t, <br />,r/6 611 —z,z 4 1 <br />Township Range Section <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) DESTRUCTION (choose type below) <br />0 SOIL BORING # fFOVER-BORE. DIAMETER '4L; <br />0 WELL # 0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS \ <br />COMMENTS:' >�YU ;•.s t� ��, �.E z Yf �l�✓l� L e�� ( �-Y lr— I'1 <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 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 0 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 certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinanc , Rules and egulations, and all applicable California State Laws.- <br />Signed <br />aws. <br />Si ned x_ 'S I 'a <br />C <br />9 Title/Comoanv (�-� �cx-, <br />Print <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, PDRESS: <br />WORK PLAN DATED: �, �, Z p , - S <br />cy a <br />Application Accepted By ! Date Issued it/ Area 1 % <br />Grout Inspection By —Date -Final Inspection By Date <br />Destruction Inspection By Date <br />N <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT!§EqYICE REQUEST # <br />INVOICE <br />e7 <br />Seo !l <br />(c <br />c%�/� SR# Z5r(lv 38 <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit_ Ern -goat-iment doc_= f <br />EHD 29-02-001 <br />6/22/04 <br />