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Q <br />San Joaquin County �P_),/7�7� <br />Environmental Health Department <br />600 E. Main Street, Stockton, CA 95202-3029!/ <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.s�gov.org/ehdl 260? <br />Well Permit Application �� <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED _FV/CES <br />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <br />a <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 ��S ,G'. 6IrKP/21Y5 S/, Cross Street 64?3S1 Sf CitYZip `�55%L Parcel# 23-3 • S Z'-' -C 1 <br />PROPERTY /f:�CY ✓o/NY Q 2 <br />Owner U411r7G /> S! -I BIZ Vlfr • Address le75 W. LOyv4-:& City i:�'/j� % Zip 15376 Phone# <br />C-57 Contractor 12S% Address 2 N <br />2o.r9" SZip <br />t7, Ci 7nxLi �{�233� p <br />ty c#' Phone#AO' 0' Ly <br />26 z V. / De.,vin <br />Consultant/ Sub Cntr 6i Address PICUa , 57-c Hu c CityS � i Lic# Phone-Lu°i <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />XNEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) p DESTRUCTION (choose type below) <br />Oa SOIL BORING # a OVER -BORE. DIAMETER <br />'WELL # 0 PRESSURE GROUT <br />a 'Other GROUT SPECIFICATIONS <br />COMMENTS: %�c /tai . S/r%.., /�a�s 1.^3 CN <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />r <br />J'INONITORING )(HOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESSStLi, TYPE OF CASING: a STEEL APVC a OTHER: <br />0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL -3"r,'02-,(/TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br />p AIR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />Q SOIL BORING a HAND AUGER GROUT SPECIFICATIONS ?rj l—I ` <br />OTHER: a OTHER APPROX. BORING DEPTH 205 ;K'3OLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <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 />Signed <br />Print Name /764/5 5/0 <br />SITE MAP IN UNIT IV FILE, ADDRESS <br />WORK PLAN DATED: 99-R <br />Application Accepted <br />Grout Inspection By_ <br />Destruction Insoection <br />COMMENTS/CO <br />Title/Company O.v i - '�O �L'Rs' Gam' �slPe'I D 4eKv <br />nate <br />DEPARTMENT USE ONLY <br />315 E, i1",-54. Lo <br />•�u�.(AL 12� �.c�c-7 <br />Date Issued <br />ate Final Inspection B <br />Date <br />� UNN <br />JOP'Qu MENTAL <br />N C� ENT <br />_Area NE�b 3�iM <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT / EST # <br />INVOICE <br />oro <br />cA S H <br />71 f3 jo -7 SR# <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment docN 14 <br />EHD 29-02-001 web <br />6/22/04 <br />