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San Joaquin County <br />Environmental Health Department SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA ��N�02 �a MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: wwi ' ov.o�/ �ro <br />,� ��10 UNIT IV <br />Well Permit Applicatior%>Q�FNT 06 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described.' l ation is made in compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environment I With De artment. 13-1_ 3t9 _ �$ <br />p�/e • L11V cblh St tA*S6*%"9- V% Si-) Va„ �„ Vreassessors C 1 <br />WELL Locatio I W�b�' `Cross Street � CityJ Zip 9 S 1.03 Parcel# <br />PROPERTY 1 1 I p <br />OwnerShLk'+orl11K'''P�V112�1�12vN �'r1C`1 Address% N. EI ]keah �oOAN?City (. V1 Zip%2D2-Phone#;-01 - 88(( tr _ _ _- <br />C-57 ContractorwobAl;aJ �r�Addresspo 1'bk 33(. City D 15 Zip 55a1 Lic#300 Phone �' 39 -30o <br />Consultant/ Sub Cntr[�Oq(,t1 96-6 Eh�N(JUfWORY�ddress(stisl 1RFHf1W N City �iT le Lic#_g3j'e s%Z -3445 <br />GIS Coordinates: X 'Y Township Range Section <br />WORK TO BE PERFORMED: <br />I NEW WELL / BORING (CPT G�7OPRO E, HYDROPUNCH, HAND -AUGER, OTHER") 0 DESTRUCTION (choose type below) <br />SOIL BORING # Z� Lj)CadU--f 0 OVER -BORE. DIAMETER <br />WELL # 0 PRESSURE GROUT <br />� *Other W d _ rv.,rL It, � / GROUT SPECIFICATIONS <br />I'1n <br />COMMENTS: WDi0O 13 Lo c -A ts, Su r + h.�du ri Lt -r / 2 k, c T_ - <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOT : MAXIMUM FREE -FALL DEPT IS 30') <br />1 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS D'L <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH ;2 o 0 BOLTED TRAFFIC BOX 0 STOVE PIPE CJ <br />&I <br />CASING PROPOSED <br />ZU , b -i S: / <br />list rspecifications 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 Or ancs, R d Regulations, and all applicable California <br />State Lawoppus... <br />Signed Title/Com anY V,u �rtSt 1,�C /�%G/o/d/n�__ Sit (�rl✓�/- <br />r� <br />Print <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDR <br />WORK PLAN DATED: 7 <br />30/0(. <br />r <br />Application Accepted By. Date Issued U 1110 v c' Area qy .2 -- <br />Grout <br />Grout Inspection By U Date " Final Inspection By Date��' o �' <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATEEST # <br />INVOICE <br />2Ct0 <br />SR S-17�t b <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit_ ncroachment <br />EHD 29-02-001 <br />6/22/04 <br />