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oul. . • San Joaquin County <br /> `z Environmental Health Department SITE <br /> e' 600 E.Main Street, Stockton, CA 95202-3029 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 compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> ,I / ' / Assessors <br /> WELL Location��/V /�/�•�,�y Cross Street✓<S� City Zip tI5 Parcel# I 1 u rf <br /> PROPERTTYYO �N..11 \ <br /> Owner•5rK ri <br /> Coldd i Address aZcoA a..."i..,�,r City54ja tf/g/ew Zip gSQ5 Phone# QLc 65 �`frir <br /> C-57 Contractor Z<,T— Address�,"Z.C3/V1 E s-1 5-b City.6W . Zip±L7Z� Lic# Phone#530 668 2-'P—y <br /> Consultant/Sub Cntr P A)!H Address City Lic# Phone# <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ,NEW WELL/BORING (CPT, EOPRO HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> — <br /> a WELL# 4LPRESSURE GROUT <br /> 0`Othc7 - - _-"" "- —- -- —-- GROI IT SPECIFICATIONS - - - ----- <br /> COMMENTS: —T—Lo bort 1c -fin <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: STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL R S 1 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE .11?USH POINT(GP or CPT)GROUT SEAL PUMPED: Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 40�5011­BORING C2) 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH SS 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: Z Sot L bo,r--"S W;// be grew*d -J'E7 Sm -Aae AF►e.- Ce r /a.'7Zd <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 Ordinanc , Rules and Regulations, and all applicable California State Laws. <br /> Signed Title/Company to "mob CS�b G✓L"b <br /> Print Name e lkk Date ' 0 <br /> D <br /> EPARTMENT U E ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: if <br /> WORK PLAN DATED: <br /> � <br /> Application Accepted By,,f9-d'L�/ppp•'�'"C� n Date Issued / Ar/e <br /> Grout Inspection ted Date (_ 0 7 Final Inspection By. /.I- je,...o-/.� Date J <br /> Destruction Inspection By Dat <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> �(�t Fe 8/q- I Oib SR#(� 5c) r� <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to Sign permit_ Encroachment doc_ <br /> EHD 29-02-001web <br /> 6/22/04 <br />