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San Joaquin County ° l� n� <br /> r Environmental Health Department fl SITE <br /> `4 4 304 East Weber Avenue, 3rd Floor, Stockton, CA 954MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjRUPvII-gt�UT 200 org/eh 6 UNIT IV <br /> P VI <br /> PO ` Well Permit Application HEALTH <br /> PERMIT <br /> SERVICES <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 /> W. �U/n��,n (;�� Assessors <br /> WELL Location ��U�` S. Lj�i,<+ra^ ?,I- Cross Street CityFt(Jlc Zip 152.3 f Parcel# i <br /> PROPERTY <br /> OwnerM,.,e-<Li-ft4;le, LL.G Address9_-5,n$• 5. H,,,la" FA_City ���^c� ip'75-23/ Phone#_l_ZvSJ 5'fz-1-173 <br /> C-57 Contractor-, FCr's-�sic,� n Addressi�l ES�PX AyaAu� City Ric Zip9y���Lic#6 Phone# /�% 23i� �1J <br /> �� �Consultant/Sub Cntr eco�.v K-SJr'"" Jdress J 14 City " 8'f i# Phone# <br /> i�1DPcr�c � <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERF <br /> p NEW WELLBORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AU ER,OTHER') p DESTRUCTION (choose type below) <br /> SOIL BO 1-C,-C F5'. FC-G9 I-C-G)C a OVER-BORE. DIAMETER <br /> 0 WELL# r J� 0 PRESSURE GROUT <br /> O'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE"a MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA:_ <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC a OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL-To Tar l &#h TREMIE TYPE TO BE USED: 0 AUGERS "OSE <br /> a AIR SPARGE/OZONE XPUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes ;KNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS_ LCMV' .9foA w 1 < 54, bCA1,)a,iE!_ <br /> a OTHER: a OTHER APPROX.BORING DEPTH `ZS a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x e /�/1,c)�uitle�-ompany <br /> Print Name Date Ib(v <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADD ES <br /> WORK PLAN DATED: I �- (j O <br /> Application Accepted B Date Issued 1 b Area' l Y <br /> Grout Inspection By Date / t`f OGi Final Inspection Byt' Date(L2 <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: Q r t e c✓ I,J 1'e Mtk'Xjp5 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 2a p 1 '$ C1- 'V�11 1515_8 SR# 4550 g <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 />