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co San Joaquin County <br /> ?� Envinnimental Health Department -w SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br /> •"" • MITIGATION <br /> (209) 468-3449 Fax: (209)468-3.433-Web: www.sigov.org/ehd <br /> 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 compliance with San <br /> Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location 6LIQ llf. �t rHiQ S'. Cross Street Oak- OZ Assessors <br /> PROPERTY City � � Zip S2Parce# 3Q <br /> - b��/� <br /> Owner 540-T1j')) r(o-('IttldtLK �ylh9ddress?V.BtgC IZ J Cit 0 Ziq;'C"L <br /> Yp ,�/ _phone# <br /> C-57 Contractor t f� Qaa�S�'dill;Ioe'Address_ �(S� �}O�y� City 1'"�u-` LAf7 Zip Iq7CS Lic#6s6 6 <br /> Consultant/Sub Cntr_ IK(d 006A 1'ZW�e,k Address 93 J Shaw Phone# <br /> GIS Coordinates:X ' Y Township Range 9 Section <br /> WORK TO BE PERFORMED• <br /> ANEW WELL/ BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 WELL#ORING#- <br /> - <br /> _ 0 OVER-BORE. DIAMETER <br /> 0*Other 0 PRESSURE GROUT <br /> GROUT SPECIFICATIONaS ' <br /> COMMENTS: <br /> r <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 7-F 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 -+-p+aA TREMIE TYPE TO BE USED: WWAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE ;PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes kNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS_ 11.(-4jaA <br /> 0 OTHER:_0 OTHER APPROX. BORING DEPTH 2-0t/ 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> COMMENTS: <br /> CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGR MENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIR FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work . I be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California tate Laws. <br /> Signed x Title/Com an i <br /> p Y � dvacucP� c o v,row� <br /> Print Name i �. -S�e� Date IZ-ZR-O�j <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: �C>L 1�":FSC <br /> 11 V 9 <br /> WORK PLAN DATED:— <br /> Application Accepted By Date Issued l 1 Z.4rc Area O <br /> Grout Inspection By (A),-Nn,A I-L— Date I Inspection By (� „rte, Date Z <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# F <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE EPEREMIT/SERVICE REQUEST# INVOICE <br /> 3 -�1 �`r�r�e�35-05 i��ja� �31ComI�z��a� SSS 7— <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />