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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 />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 />PROPERTy, , <br />-1C, <br /> <br />Owner --)-10./4—. - Iv\ Address -C103/fAC g °9--4- City 1777-tv‘,4+-ti- Zip Ct 4153IPhone# <br />C-57 Contractor UJC:tr.) r)v--lc-."-CYDrs.1 ) / -Address '?:'-:(i)c 33 6 City/2 f& V14-ZipW57( Lic# ' - -Phone# 9T37'( ti 30 D <br />Address 2.170 (Trikt.--...) City,..c.,(- 4....447 Licit Consultant/Sub Cntr j (ZS Phone#C( it 015 <br />GIS Coordinates: X <br /> <br />Township Range Section <br /> <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) 11-DESTRUCTION (choose type below) a SOIL BORING # -0-OVER-BORE. DIAMETER , ri WELL # a PRESSURE GROUT O *Other GROUT SPECIFICATIONS <br />t , /MR >S) <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />a HOLLOW STEM DIA. OF BOREHOLE J MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL Q PVC a OTHER: <br />D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED. a AUGERS a HOSE <br />0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: fl Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />HAND AUGER GROUT SPECIFICATIONS <br />a OTHER APPROX. BORING DEPTH i] BOLTED TRAFFIC BOX or Q STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />SITE <br />MITIGATION <br />UNIT IV <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />Cross Street WELL Location .? Iv. „ Assessors <br />City I 1-e.4-LX Zip (i 5:3 Parcel# c:-t ?lb 119, <br />COMMENTS: <br />TYPE OF WELL <br />'I-MONITORING <br />0 EXTRACTION a AIR HAMMER/DRIVEN <br />El VAPOR <br />fl AIR SPARGE/ OZONE <br />fl SOIL BORING <br />fl OTHER: <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 Ordinance , Rules a d Regulations, and all applicable California State Laws.1---c.--); -134-) - <br />Title/Company (1L3 i—A1Q J' <br /> Date CliZcV(7 <br />Signed x <br />Print Name <br />DEPARTMENT USE ONLY <br />SITE MAP MAP IN UNIT IV FILADDISS: <br />WORK PLAN DATED: --)‘-.7)-'r 7 6 2 6or <br />Application Accepted By Date Issued /0/ 6/ Area 9 <br /> <br />Grout Inspection By <br />Destruction Inspection By& • v'fq <br /> <br />Date <br /> <br />F al Inspection By <br /> <br />Date <br /> <br />Date 2 • <br /> <br />COMMENTS! CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERNH-T-t EST # INVOICE <br />k-c r.tos c - 1112 Ai/ '0 kr---sa# ' <br />C-5 7 WC -WAIVER C-57 Letter of Authorization to sign permit---Erz rouchment doc <br /> <br />EHD 29-02-001 <br />6/22/04