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San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />SITE <br />MITIGATION <br />UNIT IV <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 / 'Wl Assessors <br />WELL Location 3535 E• C� �E Cross Street 10N C <br />AVEity `}a0 Zip $Zf15 Parcel# <br />PROPERTY <br />Owner &;k%mi. �yr�i...i r !- io t��tGN"� Address �a N�tI�R C vt -city Atn hcclk Zip 4� 156 Phone# ��25� �S�'Z�i6 <br />C-57 Contractor W S�,4AOTWAddress Ott CJ1 we RA —City—&:�Zip q%3 Lic# fPJLPhone# 016 313-"i ' <br />Consultant / Sub Cntr A�Wj�.N t� �POGV VD"j Address S37 ' �kW 0 City SN( IA Lic#_k&Z, Phone# (7j0`1) Obi -j&, <br />GIS Coordinates: X , Y , Township <br />Range Section <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING (CPT, GEOPROBE, HYDRClal-o 1 It HER*) 0 DESTRUCTION (choose type below) <br />SOILB!L,I� 0 OVER -BORE. DIAMETER <br />0 ELL # 0 PRESSURE GROUT <br />*Other MAR2 GROUT SPECIFICATIONS <br />COMME TS: LOO6 <br />pu�ip L��' <br />TYPE OF WELL INSTALLATION TYPE CONSTR41Q�Oft1 ,�ReftknONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE Z 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 I C'TREMIE TYPE TO BE USED: `AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE PUSH POINT (GP o(CPT GROUT SEAL PUMPED: 0 Yes ;5,No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS H cone. <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH 1101 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 Ordinances, Rules and Regulations, and all applicable California <br />State <br />(�Laws. / <br />Signed �411L �� II Title/Company S GeOIOgIS, d CZeoFtvI(eptWe�.%?zr..1 <br />14 <br />Print NameDate C 23 v(p <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted <br />Grout Inspection By_ <br />Destruction Inspectio <br />COMMENTS / CONDITIONS: <br />DEPARTMENT USE ONLY <br />13 S3S G" <br />Fir <br />Date <br />-Date Issued_ <br />al Inspection By <br />64o- <br />cb� <)) 3so3 <br />ACCOUNTING ONLY: AID# <br />F <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY DATE RMIT / SER EST # <br />INVOICE <br />So 13 <br />i <br />23� <br />3 2fi SR# <br />C-57-1/ WC \,/ -WAIVER-* C-57 Letter of Authorization to sign permit ncroachment do <br />EHD 29-02-001 <br />6/22/04 <br />