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San Joaquin County <br /> z 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.sj-ov.org/ehd UNIT 11/ <br /> 'Ftf. <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 /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> p ' �T Assessors <br /> WELL Location Z�Q 3�L S. �q+��a� Cross Street S. ��Q�rr City 1 4r°,� Zip S 3o Parcel# aZ 53--1 5-O�o <br /> PROPERTY <br /> Owner r ,,Q f(\Q.44,.co.- Address Z-3 yZ S,QY. <br /> o. k 0-, City c,opt U_Zip C A Phone# $ 3 �-'�[ S 4,3 <br /> 25�ak-�.. o1Sb�) Cs-t-7z�9a4• <br /> C-57 Contractor a-w Q Address Q O Uc# Phone# <br /> ns /Strb•6ntr GQJ A oea\ 1,0� Address \\O I S� Citp':)d io Lic# Phone# 12 <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> V NEW WELL/BORING GP',lgEOPROB HAND-AUGER,OTHER') n DESTRTION (choose type below) <br /> p SOIL BORING# n OVER-BORE. IAMETER <br /> n WELL# 0 PRESSURE GR <br /> 0`Other GROUT SPECIFICATI <br /> COMMENTS: 5A." OaA'�T-ctiaf'& <br /> TYPE gF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING S HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: _ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> n VAPOR n MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE n PUSH POINT(GP or CPT)GROUT SEAL PUMPED: n Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> n OTHER:_n OTHER APPROX.BORING DEPTH n BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> //'� `� /n�sX � r CONDUCTOR CASING PROPOSED (if YES,fist specifications in comment section) <br /> COMMENTS: V.00 l/la 16 3 6::� <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 Ordinan s Rules afnd e i ions,and all applicable California State Laws. <br /> Signed x 4 \ f T _�� Tilde/Company P G C T� l <br /> Print Name V�i >1V10� `���o�-np.-D -�— Date S� > �b <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By LkA6eita Date Issued AreaTq 7 <br /> Grout Inspection By Date v(P Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: S <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> C-57� WC„_,_,_-WAIVER_,,. C-57 Letter of Authorization to sign permit Encroachment doc____ <br /> EHD 29-02-001 <br /> 6122,'04 <br />