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`'an Joaquin County <br />Envirouumental 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 />Assessors <br />WELL Location r :'0 'C wat-Cross Street "!{"r/ 7'-�i City ,f}?CLjV L-, Zip Parcel# ��• l/ �'C .j <br />PROPERTY n / <br />Owner (�c�ri �; t��/Vj�1� !�5,,���c�� Address �(,Ci� 5- �'r('�'rT �� City l6A(VA Zip 1?�'( Phone# .� -,ZZ((J2 <br />C-57 Contractor C.1, Pr"A-1) Address ftix 3 city 04-'f'(1a Zip`(J-t6( LXX Phone# <br />Consultant/ Sub Cntr KTIC Address / City Lic# Phone# 'fi/D <br />GIS Coordinates: X Y Township Range Section <br />�D, !�( ti (t�I� �! <br />WORK TO BE PERFORMED: 11 11 ``1%L� \�� . <br />ANEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') 0 DESTRUCTION (choose type below) <br />L # <br />�O 80 BORING # I -I ! rlur,,Cl; }f 1 `> OCT 2 2006 0 OVER -BORE. DIAMETER <br />PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />COMMENTS: ENVIRONMENT HEALTH <br />ADIP—MA -- <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />c� <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />�n <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 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH -_� ` G -i <br />- 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 Ordina es, Ruts and Regulations, and all applicable California State Laws. <br />Signed j1 p� Title/Company Gi-(� C--ki glr.QQPVIv1 <br />Print Name ApLl(y-'w / �` � Date 1'() <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: Z 1l S-) /�i'C ,- " � <br />WORK PLAN DATED: r\ U' VL t 2 CO C, <br />Application Accepted B / t , ` L Li F Yt Date Issued / �-2 C 6 Area %- 5 cF <br />Grout Inspection ByDate -U G Final Inspection By d�Uate 7 04; <br />Destruction Inspection By / Date I <br />COMMENTS / CONDITIONS: \1611 a 1L USL Sili I 0 <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE QUEST # INVOICE <br />3 i <br />89 <br />or <br />sR# UG ti� '7 c� 3 <br />C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permi oachment doc <br />EHD 29-02-001 <br />6/22/04 <br />