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San Joaquin County <br />Env,.,)nmental 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 />/' l" Assessors <br />WELL Location 7,Zr'71:7 `� � v4" w Cross Street C/,�}=` !` Cityr!11p�Gv1 Zip 41 20(o Parcel# Aha -090 i5 <br />l t LRT Ar ►4 DrQ, ",,Ip � 7AX l r <br />PROPERTY <br />Owner A�7'fl�I-uJ q Address rI e�Ji �� -'r City L III Zip gr72_,'�� hone <br />C-57 Contractor 4t )Zt1 A1�VJ 4WICVL_Address 3D09 �EQSQ � �tCity 6ttAU [6 Zip 9��Lic#fyq� Phone# gx-90-'13�I�i <br />Consultant / W1C QWddress L4I W11ytA �Q� �1'*'5'ity oY2rd0�`1c# / Phone qIL 1 '� <br />GIS Coordinates: X Y Township L �i Range i0 Section ZZ <br />WORK TO BE PERFORMED: <br />NEW WELL I BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) \` <br />0 SOIL BORING # l 0 OVER -BORE. DIAMETER <br />`WELL # SUS 1 U —1 Z S�'t'`�Z 3s- s S 6 sti / 0 PRESSURE GROUT <br />0.Other T GROUT SPECIFICATIONS <br />COMMENTS: Lc.wl <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING HOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION �0 AIR HAMMER/DRIVEN CASING THICKNESS 40 TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL O TREMIE TYPE TO BE USED: j9AUGERS 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 AA" C21tilC'� <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH C75 BOLTED TRAFFIC BOX or 0 STOVE PIPE `C <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section)' <br />COMMENTS: Z?e-P, a Gi we'u <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. C <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 Or Inances,CR�u,lless and Regulations, and all applicable California State Laws. �f <br />X Signed f�t� W J W Title/Company �� C-7-ce S T:D �NIIfLQ�►UI'FEbJTQL ��IC <br />9 , <br />Print Name �� �� h 'D�` G �" Date <br />1b� <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: ZZ s 5 5. A'' C 0 <br />WORK PLAN DATED: cm"'-to'� tot -t31 V" } <br />Tt u.k,w - l <br />Application Accepted By / -� r Date Issued 7����D <br />Grout Inspection By Date Final Inspection By ate Z l2� J <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE QUEST # <br />INVOICE <br />03 <br />4.00 �g3•o� <br />�S�OZ <br />�-c SR# <br />C-57__�,,/ WC__j,/- WAIVER <br />EHD 29-02-001 <br />6/22/04 <br />C-57 Letter of Authorization to sign permit_ Encroac men oc�✓ <br />