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San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />SITE <br />MITIGATION <br />UNIT IV <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 />a L Assessors n <br />WELL Location C, C) �/ c a c�J Cross Street J'i'n 16.1 City LSCS �� Zip Parcel# <br />Co <br />� LL// AA <br />OwneERTYS \ .J.�� Address 1x 0 WA 2Q 16-� 14— City �IocV"f\ Zip �S ZcZI Phone# 20`1-Y1< �3640 <br />5-6 C-57 Contractor �l re X R !J f \ I ? T4 Address Ti U �0 W d . City u� t Z Zip S SJ Lipt yC z Phone# Z5 ' 31 3 �S �U <br />Consultant/ Sub Cntr KLI)Add Address >~ z 2 / rnT City 6wt �.tia Lic# Phone# y/S _Z y3 Z�SO <br />GIS Coordinates: X- j Z J• C�-1 1 g S 'Y �-3'yy 1 6 Township 11 'S Range Section 3 6 <br />WORK TO BE PERFORMED: <br />* NEW WELL / BORING LqPT, GTttPW BE, HYDROPUNCH, HRW-AUGER; OTHf-R*) 0 DESTRUCTION (choose type below) <br />`(j SOIL BORING #C1�I -� -q��0�-Ifs 0 OVER -BORE. DIAMETER <br />0 WELL # ^T 0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />PE CODES <br />COMMENTS: -- <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE_Z2�a 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: ------ <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 90 .� t TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE USH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />r <br />SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS A/ trX al -• <br />OTHER: L t T 0 OTHER APPROX. BORING DEPTH RC) 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />t <br />CONDUCTOR CASING PROPOSED 0 (if YES, list specifications in comment section) <br />(J <br />0 <br />COMMENTS: <br />a -9a T <br />am.. <br />-VL 11�61. � <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />1 <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />kA <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin t <br />County Ordiponces, Kuuuies and Regulpations, and all applicable California State Laws. (� <br />Signed x, �t `�-�' Title/Company Geolo ist/Kenned Jenks Consultants Inc. <br />Print Name Mike McLeod, P. G. Date Z ®6 <br />N <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: Z l 56t3 l F R �- - I ) <br />WORK PLAN DATED: <br />Application Accepted By - Date Issued ( �O } Area <br />Grout Inspection By `/��w..Cc� _Date Z C' Final Inspection By ��..uAo+1 Date o ` <br />Destruction Inspection By Date - <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# G! II <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />a -9a T <br />am.. <br />-VL 11�61. � <br />�-3z <br />( <br />zZ� � <br />SR# q � �-- <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 />