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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 /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> <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 3(-11 77-6,_, 311., Cross Street C (0Je-i City j -sc,64,71 Zip 75-3.1-& <br />Assessors <br />Parcel# (:)/ ()2_() <br />PROPERTY <br />Owner A- R. Cc) Address City Zip Phone# <br />C-57 Contractor k}..)0b vio..._c) b1-11(i >Address -?t' '2)0K .-?.-.,- Cr City ik)e) 1i/-‘k Zip s-,"`6 ?- i Lialt I 6.1-1 Phone# 407 3? -j- `--/.40 o <br />Consultant/Sub Cntr J Q. S Address 2-5 ?rn G--a-4CLocy.tics City .5a.Cia•......de L a Phone# cff 4 -6 7 t ZZ,G ( <br />sP A-o o <br />GIS Coordinates: X , Y Township Range Section <br />WORK TO BE PERFORMED: <br />a NEW WELL! BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") IrDESTRUCTION (choose type belgw) <br />O SOIL BORING # WOVER-BORE. DIAMETER /c. '',,, ie <br />0 WELL # 0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />3 ( oc,---6 COMMENTS: '';1 I 0, u..5/ 0 /( <br />C-57 <br /> <br />WC <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />WMONITORING ,)fl HOLLOWSTEM DIA. OF BOREHOLE 10/+-/- 0 MULTIPLE CASINGS g MULTI-LEVEL WELL CASING DIA: 1 <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL WPVC a OTHER: <br />0 VAPOR 11 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: tfr(es I] 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 -3 S— / 04 C1A a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />/ CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) ./ <br />COMMENTS: 9 - 7--- ,..3...,1k Ce, 2..s-- 3 5---/ - 3 — '/" ,...., 1 ( ,s (...;) 2 7 <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 State Laws. <br />Title/Company 0 a 3 <br />Date e/3 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRIESS: <br />WORK PLAN DATED: (-(pl 7r i 2-CeS <br />Application Accepted By 4)1<y-3-L. ( Date Issued 1(4 lac Area <br />Grout Inspection By Date Final Inspection By Date <br />Destruction Inspection By 71---ikA4))-e4 Date <br />Signed x <br />Print Name '/V\C ( <br />COMMENTS! CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE "J. jal u-i-ez-Rmt-e-fThittnigs,:r # INVOICE <br />cc( :lc-It( 41, tol,f,(- sR#,c______ <br />-WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br />EHD 29-02-001 <br />6/22/04