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San Joaquin County U UEC <br />E ev"k,� <br />Environmental Health DepartmeAlt,,; w� SITE <br />304 East Weber Avenue, 3rd Floor, Stockton,`6AP5/202� `S�OQS MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www. syUNIT IV <br />Well Permit Application ��� ,(',I <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED UHIGINU <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 />�� 1 [� Assessors <br />WELL Location `3 ��3�) E C ��< ulrt' �c� Cross Street "ko 't� 4 City Ck= Zip 1 ��5 Parcel# <br />PROPERTY c f <br />Owner E l)(5 C('« i•1F Address 30CC! E-- late` •fit City 2,AA Zip 14Wj 14WPhone# (I25) -20rg <br />C-57 Contractor Dit(I ?�Z Addres''s--11 ��{(� +U 1+ �> A-J,-vw.e.. CityC=VffV ZipgSSaj Lic#� IZu it Phone#( -10"1 qqq--`j0q,- <br />Consultant/ Sub Cntr MVOJAL'£n Q aiu,►ORVACtkddress %3'1 6,au,�,' City .L ' C Lic# & '6 _ -� Phone# c C' o 4 <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: r `, <br />'ANEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER") 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />jKWELL # 'Z - 0 PRESSURE GROUT <br />0 'Other `t GROUT SPECIFICATIONS <br />ILA <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />PE CODES <br />}MONITORING HOLLOW STEM <br />DIA. OF BOREHOLE_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />CHECK # <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />CASING THICKNESS 0 TYPE OF CASING: 0 STEEL "&PVC 0 OTHER - <br />31501 <br />503 <br />0 VAPOR 0 MUD ROTARY <br />DEPTH OF GROUT SEAL �� TREMIE TYPE TO BE USED: D AUGERS VHOSE <br />2213 ( <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 'Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />.Z SR# too3j <br />0 SOIL BORING 0 HAND AUGER <br />GROUT SPECIFICATIONS 'P,, +l ",n <br />O <br />0 OTHER:_0 OTHER <br />APPROX. BORING DEPTH IDc'-)' 0 '10' ie°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 <br />application and that the work will be done in accordance with San Joaquin <br />County Ordinances, Rules and Regulations, <br />and all applicable California State Laws. <br />Signed x U �s L� <br />Title/Company ]�Gdt l'_1Jc11T/ii�iUdiA�� �wV,rGLt�4t�K(Yti+�i�! <br />. <br />Print Name E � r -e 'v-, <br />Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS:_ <br />3535 . C�c 2�,�z2, 15K%_ <br />7� <br />WORK PLAN DATED-: 20MAy 05 <br />Application Accepted By C—Q <br />Date Issued Area <br />Grout Inspection By <br />Date Final Inspection B Date <br />Destruction Inspection By <br />Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />FAC# ' <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE P R T # INVOICE <br />31501 <br />503 <br />z 9. <br />36S <br />2213 ( <br />.Z SR# too3j <br />C-57 ✓ WC ✓-WAIVER_ C-57 Letter of Authorization to sign permit/'nhff C&Mthff-&E <br />EHD 29-02-001 <br />6/22/04 <br />