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San 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 /> c. <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 /> ! d(fL3;� J-( fLl — - / 't!' S`f/l Assessors <br /> WELL Location i C Cross Street CityJ�rl Zip Parcel# 128 I f'f 030 <br /> PROPE TY `" p <br /> Owner Vl k:iOr•i P. �q;`.:. rF/s SAddress {� ,), d." ,` �~ City , Zip q t� Phone# <br /> C-57 Contractor J :'� I i'r�9 Address I 7� �E/Of'' .1'f'+'` Nle-city'tI<'ltt; Zip/?��1~��Lic#Phone# t f %' ' l -�— <br /> � '� <br /> //�� �` � / t ti <br /> Consultant/Sub Cntr EI `t,3 k5- Address.. � -' +` 2 <br /> � �V l�°C (�, (�� ft'i ?"�tr�`> city, <br /> '--�' Phone# {}%1 <br /> GIS Coordinates:X _,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> \dNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) p DESTRUCTION (choose type below) <br /> []SOIL BORING# \ a OVER-BORE. DIAMETER <br /> ; ELL# !' %=.t ts',_.;_.t£1 fi lc r f,AaAu'i o '4 ) O PRESSURE GROUT <br /> OtherIDOE,Mgb / GROUT SPECIFICATIONS <br /> COMMENTS: _ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0.MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL >.PVC p OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS 0 HOSE <br /> p AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: P es 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING O HAND AUGER GROUT SPECIFICATION N-'r <br /> OTHER:`` oi', 'Y(' 0 OTHER APPROX.BORING DEPTH i (? '"{f> 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: ! ,f.. '�) >y. 0('A'.A, - Cdr( �Ic'.t 'a,t %� 01h��. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify th have prepAd this application and that the work will be done in accordance with San Joaquin <br /> County Ordina a Rule d R gula ions, and all applicable California State Laws, <br /> Signed x Title/Company Alrodq- ANG <br /> Print Name Date��2;/ ____ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 2 t-C-,Cl <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued 1 D 1 A 1&4k Area <br /> Grout Inspection By J,(�g A A.A C 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 I SERVICE REQUEST# INVOICE <br /> -'h'00 vxc>/* Gv< In &(a-0 SR# 5562-5 <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 />