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i <br /> +: San Joaquin County <br /> Environmental Health Department SITE <br /> . ALTH 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 MITIGATION <br /> ICES(209) 468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED �C. Nei <br /> Application is hereby made to San Joaquin County for a permit to construct arWorJnstail the work described. This application is made in compliance with San <br /> Joaquin County Development Idle,Chapter 9-1115.3 and the Sizndards df San Joaquin County Environmental Health Department. <br /> p�� Assessors <br /> WELL Location_ i9� 9 M�k...ley Amo— Cross Street City ocr--- Zip Parcet# 2K 1 2C,0 0 <br /> PROPERTY <br /> Owner Address 1E�c(i`s'�niaClc� City ic��n5a Zlp a?5(APhone# �U b 2112 rt(f, <br /> ID <br /> cG <br /> C-57 Contractor �/`I� L Address gceqllle�el Q++2 City�+� �+ZJpjLic# '3�4Phone# �1o''?r�l5 <br /> Cansultantl Sub Crrtr_ _ hh +Address j c 3a'�b'7 Clty L]+ .e Lic# JY �`fo Phone# y vlgc6 <br /> GIS Coordinates:X Z'— Y Township Range Section e� <br /> WORK- <br /> To BE PE FORMfl: __ _ a _ 1Ao NEW WELL 1 BORING (CPT, GEOPROBE.HYDRCPUNCH,HAND-AUGER,OTHER-3 0 DESTRUCTION (choose type below) � C rD <br /> a SOIL BORING# Q OVER-BORE. DIAMETER � <br /> Q WELL# RESSURE GROUT <br /> O'Other / GROUT SPECIFICATIONS <br /> COMMENTS: <br /> V/}`y^,p�"�"�} <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING U HOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> tl <br /> U IXTRACTION 0 AIR HAMMERIORIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 CTHER: <br /> 0 VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Q AUGERS 0 HOSE <br /> Q AIR SPARGE!OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes No : MAXIMUM F E-FALL DEPTH IS 30') <br /> 0 SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS <br /> Q OTHER: rl OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list spechIcal7PERMITS. <br /> COMMENTS; t Ci4 I "2. FRGts A LI 2" 'i '-w NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHME <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> Sherebycerti hatIhav pre ared this application and that the work will be done in accordance wiuin <br /> County Ordi a egulations, and all applicable California State-Laws. n <br /> Signed TitlelCompany / i Lr -14 yty� art' <br /> Print Name Date <br /> Y-,•, _., _� . .. DEPARTMENT USE.ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS .o `f' <br /> WORK PLAN DATED: $ <br /> Application Accepted By Date Issued <br /> S� Area <br /> Grout Inspection By 7 Date Final Inspection By Date <br /> Destruction Inspection By Date — le-1 <br /> I <br /> j COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AIDER ;ACX <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT I SERVICE RECUEST# INVOICE <br /> py D 64. 1�5 g sR# I <br /> C-57� WC`WAIVEs2_ C-57 Letter of Authorization to sign permit Encroachment doc �✓ <br /> 8HD�9-02-441 <br /> I 6122/04 <br /> i <br />