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an Joaquin County <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 <br /> UNIT IV <br /> '.q(•�F pR�� <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 /> (� n �i Assessors tJ <br /> WELL Location 40 rre,nr �a va !1 Cross Street �. 11l' I eS pity Vrepth&Vip 523 Parcel# / �— -I -13 <br /> PROOOwneERT� Address / Q( lP City Zip l one# 915173— 12-0 <br /> C-57 Contractor Address City Zip Lic# Phone# <br /> R a^�kv AJd �y>/ U <br /> Consultant/Sub Cntr S cco Address s D 0 1<1 I/ <br /> FPC IS <br /> � C o r�"Lic# // Phone# !/(10 O o <br /> .GIS Coordinates:X 'Y Township� ) S Range (o Section 1 <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 YVELL#_ ` 0 PRESSURE GROUT <br /> X'�*Other Q'M -t I' rt;i� �"� S GROUT SPECIFICATIONS <br /> COMMENTS: -PQ frie oA 5-r 1 /1 <br /> TYPE OF WELL 11'1/y <br /> INSTALLATION TYPE A�CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: --- <br /> a 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 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> OTHER:• 0 OTHER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> am COMMENTS:q a N Ua C iA l�t o Gt S O F i�C d �l4 S <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> .r 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify that I have prepared t is application and that the work will be done in accordance with San Joaquin <br /> County Ordir)ances les and Reg tions, and all applicable California State Laws. <br /> Signed x /n7 Title/Company�h t A 'OQ <br /> Print Name G--A 14-64 P-C K Date 'T —O S7 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> .WORK PLAN DATED: <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> . SR# <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 />