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°"'" San Joaquin County ' '� �— <br />r Environmental Health Department'` SITE <br />i 4 304 East Weber Avenue 3rd Floor Stockton CA 95202 <br />' MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: w�A,.sjgov005 <br />.org/ehd ? <br />N�P�f UNIT IV <br />�rF - Well Permit A lication �ln!` _iti'l <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 />'',,11 - Lr Assessors <br />w <br />WELL Location I tP9 • Ge Mrt r j Cross Street i)(, .k city AL = L` f2 Zip (iJ ACL i Parcel# <br />AID# <br />PROPERTY LDSt'-5 WLL <br />�- -7 '] <br />Owner_ C*)D to Address o;?Joa VtrALl CCL City 5 CkjCfl ZipSl�CgPhone# <br />FEE INFO <br />C-57ContractorvNGiC', T -)k I✓tG), AddressgSC' HOt�_ wx�.C\ City♦tvt2LZip`i�S�3LiC*44.EIb,SPhone#Ida`�� 313 - <br />CHECK # <br />Consultant / Sub Cntr(� (Ck ( 1-0 11'IC -'-;,Address __1101 I)"i t - City1LLQLL `_Ltl.Jo# Phone# i ,7Cf i� 51 ,2 <br />DATE <br />GIS Coordinates: X Y Township Range Section <br />INVOICE <br />WORK TO BE PERFORMED: <br />D NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) .0 DESTRUCTION (choose type below) <br />D SOIL BORING # D OVER -BORE. DIAMETER <br />-- <br />0 WELL # ,jWRESSURE GROUT <br />Z. <br />0 'Other GROUT SPECIFICATIONS_ <br />si <br />COMMENTS: <br />_ <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />;$ MONITORING 0 HOLLOW STEM DIA, OF BOREHOLE 0 MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br />D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC D OTHER: <br />-� <br />D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />D AIR SPARGE/ OZONE D PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />D SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS_ <br />D OTHER: 0 OTHER APPROX. BORING DEPTH D BOLTED TRAFFIC BOX or D STOVE PIPE <br />CONDUCTOR CASING PROPOSED ��— - (if YES, list specifications in comment section) <br />t <br />COMMENTS: r�. `�E� �� (kC.b �ccl k E�Iri (l 1 <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 Ordi ce s and lations, and all applicable California State Laws. <br />Signed x�i Title/Company <br />Print Name �i Date 9 z <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />� q <br />Application Accepted By Date Issued C�Vll !�` 00 S Area <br />Grout Inspection By Date_ Final Inspection By Date <br />Destruction Inspection <br />COMMENTS/CO <br />Date <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />�- -7 '] <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT 1 SERVICE REQUEST # <br />INVOICE <br />35oZ <br />�''oi�$�' <br />�tzz0� <br />sR#n?3 <br />C-57_ WC----WAIVERC-57 Letter of Auth lza ion o sign permit_____ Encroachment doc! <br />EHD 29-02-001 <br />6/22/04 <br />