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ILL�o San Joaquin County <br /> v Environmental health Department SITE <br /> 4: .t <br /> 304 East WeberAver .ie, 3rd Floor, Stockton, CA 95202ILL, MITIGATION <br /> y ' (209) 468-3449 Fax k 1 ) 468-3433 Web: www.sjgov.org,'ehd UNIT IV <br /> Oq L' N�P <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 7 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 /> yy QQ ,r ' ' ' .1�,� � ., t,, ,, �� l rAssessors <br /> WELL Location IVO /V t,�i � tom@ Cross Street r^'t-lv a city 6n� zip �J aa arcel# � � �r 12 6t, l_ <br /> PROPERTY cI <br /> Owner . III Address r (J ` ane# � C p <br /> C57 Contractor rj f'L`t"\( J4^�n„ Adar s o��`- w u>c�rn c + `f i <br /> J 1 n -tic# 5 '-' r-; iondl / <br /> Y _ t? r - I <br /> Consultant / Sub Cntr /)ti ,�L�� ` Address 5J t, , �yff ty �YlCYaf''Vu# 40 Phone# <br /> GIS Coordinates: X Y., Township Range Section <br /> WORK TO BE PERFORMED: <br /> n NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) DESTRUCTION (choose type below) <br /> 0 SOIL BORING# OVER-BORE. DIAMETER <br /> 0 WELL # PRESSURE GROUT <br /> 0 *Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING p HOLLOW STEM DIA. OF BOREHOLE_ 0 MULTIPLE CASINGS n MULTI-LEVEL WELL CASING DIA <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: n STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS n HOSE <br /> 0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: aYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING n HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER: 0 OTHER APPROX, BORING DEPTH n BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDU TOR CASING PROPOSED (if YES, list specifications in comment section) <br /> COMMENTS: S , ,) L ( Iti� wrAll — Eur, /.� <br /> NOTE : OFFSITE BORINGS REQUIRE ACCE S AGREEMENT OR ENCROACHMENT PERMITS. oma® <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County =f' l <br /> les Indulations, and all applicable California State Laws, <br /> 41 <br /> Signed / Title/Company QL� f1aQ i rz PrintNamee n . A A Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : 17 ( D P"{41 j {tto �r E i" '� + ee I- <br /> WORK PLAN DATED : nJ( 22y air / ) , TL0 r <br /> Application Accepted By-. <br /> � C-;f � i^ iFG - lrl� C. (7 r^ 'I-i'f � , " Date Issued - rE � i"Flf� : t .7_ f ulir' S Area - fir 5 j <br /> Grout Inspection By Y jyl Ury a Date .2 16 Final Inspection ByY i a�TYS w)71 .tinrYrC. Date 2 8 O r <br /> Destruction Inspection By Date J / <br /> COMMENTS / CONDITIONS: <br /> ACCOUNTING ONLY: . AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT 1 SERVICE REQUEST # INVOICE <br /> SR# <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment clot_ <br /> EHD 29-02001 <br /> 6122/04 <br />