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aSan Joaquin County <br />Envirlimental 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 /> <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, C pter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />WELL Location ISkPa4— <br />ss <br />Cross <br />Assesor <br />4711 eel Z p Parcel# I I o 3 at I. <br />ERTAI <br />I Otibrif Address 6.2b5C(2 Cityirry-161-4.4 Zip 9- 32khone# 957- 123 7 PORwOnePr L, <br />C-57 Contractor441(.142 6-6) 4-3tfiCR .7C-kat.0 p ei521 # ??ne# 46? W6(0 <br />Consultant / Sub Cntr /9-6C Address <br /> <br />City Licit Phone# <br /> <br />GIS Coordinates: X <br /> <br />Township Range Section <br /> <br />WORK TO BE PERFORMED: <br />)(NEW WELL / BORING (CPT, GV)PIRQBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />OIL BORING # <br />IfWE LL# <br />O *Other <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATI.ONS <br />l] MONITORING a HOLLOW STEM DIA. OF BOREHOLE Z Vi'1310tULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />O EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NA--TYPE OF CASING: a STEEL a PVC a OTHER: <br />O VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 6.1).FGLIP-4-1REMIE TYPE TO BE USED: 0 AUGERS a HOSE <br />O AIR SPARGE/ OZONE USH POINT r CPT)GROUT SEAL PUMPED: a Yes 0 No (NOTMAXI UM F EE-FALL DEPTH IS 30') <br />OIL BORING 0 AND AUGER GROUT SPECIFICATIONS <br />THER: 0 OTHER APPROX. BORING DEPTH VP 1-:€524--- 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, Rule and Regulations, and all applicable California State Laws. <br />Signed x 04 I Title/Company .11--- /146 C <br />Print Name 1/1) i i t_.44,.„., c t---HQ Date jAS l9 <br />U DESTRUCTION (choose type below) <br />0 OVER-BORE. DIAMETER <br />U PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By,4 A/J/1- 4.A.cjit-4- ' <br />Grout Inspection By <br />Destruction Inspection By <br />DEPARTMENT USE ONLY <br />'nil pat: <br />Ain, 1, <br />Date Issued <br />Date Final Inspection By <br />Date <br />Area 34 t <br />'Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# R1O £)/(<9 0 <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT! SERVICE REQUEST # INVOICE <br />ci 10101- <br />SR#5-19.11 <br />C-57 "WC <br /> <br />C-57 Letter of Author'zation to sign permit Encroachment doc <br /> <br />EHD 29-02-001 <br />6/22/04