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pan Joaquin County ORIoWiAL <br />C <br />9 t3' (o <br />Environmental Health Department u��LS[Jv 'i SITE <br />600 E. Main Street, Stockton, CA 95202-3029 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 web: www.sjgov.org/ARP _ 7 100$ UNIT IV <br />Well Permit Application ENVIRONMEN-1HE <br />1. Al REFUNDABLE PERMIT EXPIRES A YEAR FROM DATE 1QQIy1P�RMIT/SERVICES <br />vk•-1��1 <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 />.1 J o,�Q,J� Assessors �/ <br />WELL Location (y (�YQr'f'C- tS+- Cross Street A `' ' N"etty Zip �2 Parcel# l3 "-32113 <br />PROPER f/ /I /� /_C'^.2��'� <br />Owner �'�G1nl''QS Yk 1bjal+� Address �7�q Fye v _,,City L Zip` 5215Phone# vU/D Q <br />C-57 Contracto Sd (1 LI% Address7f/�2.. c(omk--' �'6/ nnciity �,�" /�Z&�ip�57q Z=ic#7!; Shone# / f� //D II <br />Consultant / Sub Cntr Address a3-7 Skflui kkCitySfD(dM Lic# Phone# lb -7 !W(O <br />GIS Coordinates: X Y Township Range Section G <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING <br />0 SOIL BORING # <br />0 WELL # <br />0 *Other <br />COMMENTS: <br />TYPE OF WELL <br />MONITORING <br />0 EXTRACTION <br />0 VAPOR <br />0 AIR SPARGE/ OZONE <br />0 SOIL BORING <br />(CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />a DESTRUCTION (choose type below) <br />0 OVER -BORE. DIAMETER Z <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />HOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE �OFFCCASING: 0 STEEL 24C 0 OTHER: <br />0 MUD ROTARY DEPTH OF GROUT SEALg5 JZ> II0f"TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED:'I'Yes p No (NOT MAXIMUM FREE -FALL DEPTH IS 30') <br />0 HAND AUGER GROUT SPECIFICATIONS PP.t <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH IZD BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />AA� <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: NAW 1 •'15 t� ` �/ P cStit <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 <br />�-%Regnj ulations, and all applicable California State Laws. <br />Signed x t�jd PC, l�`'`��`,�j� Title/Company��a�. �� <br />Print Name 4N I, I `L6x �'I ,I `� Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 3 0 A ^i OY-+IA G Y -a n T ee I <br />WORK PLAN DATED:e r U a f�' o <br />Application Accepted By r' , L, / e Date Issued '4 -8 - o 8 Area 1 � S 9 <br />Grout Inspection By we"l[b el � 14eArfaton Date -1 -6 Inspection By ll(j � k,6 L, M, ate 5 `3-0 S <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: 11qS+6iI i ri eel <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE ICE REQUEST # INVOICE <br />35-01 <br />o3 <br />294 od <br />383.00 <br />27306 <br />1 VW <br />4-9-04-S"": 005-383 <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit_ Enc oc_ <br />EHD 29-02-001web <br />6/22/04 <br />