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Van 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 UNIT IV <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 /> Assessors <br /> WELL Location Cross Street Cit W 5 <br /> YZi P q 330 Parcel# 213—x°10' 17 <br /> PROPERTY <br /> Owner_R,Wer =Slwnr-t-s Address -73 W. RA.City LmAm,P Z05334 Phone# <br /> C-57 Contractor RfiSonlanL Address 1-46 N. Eu 54 Slree l• CityNcrA nA Zip957'7(aLic# /. uPhone# 550 &&S—A7,4 <br /> Consultant/Sub Cntr EN(o F-a 'Lnc. Address 7980 N. rr•wa9 Rfvd City;Range <br /> Lic# Phone# � $SS-p(,/6 <br /> GIS Coordinates:X 'Y ,Township Section <br /> WORK TO BE PERFORMED: <br /> f,NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH HAND-AUGER,OTHED TRUC ION (choosetype below) <br /> 0 SOIL BORING# RE.ODIAMETER <br /> a WELL# P U EGROUT <br /> $'Other CIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTIONVE IFICATI S <br /> a MONITORING a HOLLOW STEM DIA.OF OL Z." UTI JYICNGS a MULTI-LEVEL WELL CASING DIA:EXTRACTION Q AIR HAMMER/DRIVENCABINHI K ESS ASING: Q STEEL 0 PVC Q OTHER: <br /> 0 VAPOR a MUD ROTARY DEPT G UT S TREMIE TYPE TO BE USED: O AUGERS II HOSE <br /> p AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROU L PUMP p Ye o (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING a HAND AUGER GROUT S CIFI I S ea <br /> p OTHER:_0 OTHER APPROX.SO G PTH 1? p BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCT CA G PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: .V �n YMIP � -mGclla <br /> NOTE: OFFSITE BORINGS REOUIP/Aw AGREEMENT OR ENCROACHMENT PERMITS. <br /> 481 HCSURS E REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application a d that the work will be done in accordance with San Joaquin <br /> County Ordinances, ules a Regulat"`ns, and all applicable California State Laws. <br /> Signedx Tile/Co mpany+ I EU)6,FO <br /> Print Name r4 Date 3/;k'/06 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, AD ESS: <br /> WORK PLAN DATED: <br /> Application Accepted ued Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <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 />