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ORIGINAL <br />. San Joaquin County <br />—CEWL �) SITE <br />Environmental Health Departmo <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.or e0 2 2005 UNIT IV <br />Well Permit Application <br />ENVIRONMENT HEALT �� <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IT/SERVICES D� *wz,3 <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 />/7016 Ire„ _ - _� (A <br />, Assessors <br />WELL Location _ �J�(-�- ross Street -�"� City i� Zip Parcel# <br />PROPERTY �d Addres b �f0 �C�'�"� ZiP� Q �(�� <br />Owner ;� j� /� Cit Phone#5u'Gb(� CiC/. ✓Z�+ <br />C-57 Contractor L YnlI i�lf�l Address �U'� V►�'�l( �w- Ci i0t 1 C Cl — 4 Phone# 3b"'�]I� <br />Consultant / Sub Cntr li�d� Address l� �1I�I�� iS �ity a Lic# Phone# ��Illx �O UlJ <br />►� <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />p NEW WELL / BORING <br />/ 0 SOIL BORING # <br />WELL # 'Ili .l) - Z <br />(CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') <br />COMMENTS: <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE. DIAMETER <br />0 PRESSURE GROUT <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />It <br />MONITORING <br />HOLLOW STEM <br />DIA. OF BOREHOLE MULTIPLE <br />CASINGS 0 MULTI-LEVEL WELL CASING DIA: _1_ <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS ; t <br />TYPE OF CASING: 0 STEEL XPVC 0 OTHER: <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEALS TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE <br />0 PUSH POINT (GP or CPT)GROUT <br />SEAL PUMPED: 0 YesNo <br />(NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS � <br />�I <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH <br />COMMENTS: <br />DUCTOR CASING <br />n -71- 27.1 <br />Y1(�1�j -�BOLT�D TRAFFIC BOX or 0 STOVE PIPE <br />SNC (if YES, list specifications in comment section) <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 />VIL <br />Signed x Title/Company {� <br />Print Name VI Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: �O S • -�// <br />WORK PLAN DATED: '57,— /.�-'D <br />Application Accepted <br />Grout Inspection By <br />Destruction Insoecti <br />COMMENTS / CONDITIONS: <br />Issued l� <br />Date Final Inspection By <br />Date <br />J <br />�� <br />mrWM <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />VOICE <br />SR# zz9 3 <br />C-57_ WC= WAIVER �-C-57 Letter of Authorization to sign permit n / O5 <br />EHD 29-02-001 / �t /`�u� <br />6/22/04 w(� <br />