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San Joaquin County ORIG L <br />Environmental 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 c pl ce with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />+R, a `1 , ` q G Assessors ' n <br />WELL Location ��S �y Dk11Y►rz 1� �1, Cross Street Star 5t. City U')A t Zip 15 4Z Parcel# X ID <br />PROPERTY <br />Owner 'r(�Co/ �� <br />f PDQ l' I - <br />—1 Qj� '1 l Address130(_'rr I,t}, LOA, A}Vt, Sok City L� �, SZ4ZPhone# Zy 1-S3 T -0 6 3 W <br />C-57 Contractor (QS✓t <br />_Zip <br />1111 �rlAddress J` �2 lilVl;i t . �tiY�L City11C'�k, 'i��ZipC��4ZLic#�I15I V Phone# �Ib �� 1 <br />Consultant / Sub Cntr <br />I� ` 1' <br />1 Ln Address II2-�4i7ufrSV��! Cit 'lf( Lic#�131 A Ph ne#9/6-85i-di�y <br />GIS Coordinates: X <br />Y Township Range Section <br />WORK TO BE PERFORMED: <br />)f NEW WELL ! BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) p DESTRUCTION (choose type below) <br />o SOIL BORING # a OVER -BORE. DIAMETER <br />'WELL # <br />RN a PRESSURE GROUT <br />l <br />a `Other <br />GROUT SPECIFICATIONS <br />(31 <br />COMMENTS: <br />S <br />TYPE OF WELL <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />�^ <br />a MONITORING <br />'HOLLOW STEM DIA. OF BOREHOLE a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br />EXTRACTION <br />a AIR HAMMER/DRIVEN CASING THICKNESS SC6gA TYPE OF CASING: a STEEL WVC a OTHER: <br />a VAPOR <br />a MUD ROTARY DEPTH OF GROUT SEAL 3 :�� TREMIE TYPE TO BE USED: a AUGERS ,HOSE <br />a AIR SPARGE/ OZONE <br />a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: Q Yes h4o (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />a SOIL BORING <br />a HAND AUGER GROUT SPECIFICATIONS 7 <br />a OTHER: <br />a OTHER APPROX. BORING DEPTH X - kee f a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />_ <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />__�� , <br />'1i- <br />COMMENTS: I ulzsX.- �7 1,l)� \, -,P- 2-S7i-iL �0 bx C�'VLLLI' SIIY I �ui'i <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. �-i- <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 CaliforniaState Laws. <br />Signed , ` Title/Company <br />Print Name h& ( Rat -HA Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS:_W 3T W. <br />WORK PLAN DATED: /D <br />Application Accepted By Date Issued ' Area_ <br />Grout Inspection By Date Final Inspection By te <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: I AID# <br />FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC-D BY DATE PE <br />'07 <br />5n'I K., _M? ( � SR <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit_ Eng <br />EHD 29-02-001 <br />6/22/04 <br /># I INVOICE <br />