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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 />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <br />2007 A 26 W 11: 47. <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED x i r I C y }FEC Y <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is mai <br />Joaquin County Development <br />j�TJ�']tle, Chapter 9-111/5..3 and the Standards of San Joaquin County Environmental Health <br />Departmel�E <br />Assess <br />WELL Location ` f Vy" Cross Street City Zip`(7�J Parcel#PROP <br />1 17 <br />OwnerERTaIjii,e I 1 Address �U guy— eC ( /1 City S� (` AZi S Phone# �`�' 2�14 <br />C-57 Contractor I,GtSLQL�/2� 1 Address�� 37 ©�1�� (�,✓�. City Zip�7zLic#717�1 `� Phone# VI b3�� <br />Consultant / Sub Cntr A—C1 C Addressg�7 S �G c; a City �Lic# Phone# 4)(017 1004, <br />GIS Coordinates: <br />iW <br />Township <br />Range Section <br />W RK TO BE PERFORMED:)YN�� 1 <br />EW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) T' <br />0 SOIL BORIN # 0 OVER -BORE. DIAMETER <br />0 WELL # %5 1 0 PRESSURE GROUT -- <br />0 *Other GROUT SPECIFICATIONS -JQ <br />COMM <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �f / <br />0 MONITORING t90LLOW STEM DIA. OF BOREHOLE J 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: ` )L <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL OVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL %Zi r�''� TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />Jp AIR SPARGE/ OZONE p PUSH POINT (GP or CPT)GROUT SEAL PUMPED: ees 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH J6 5 f5��+ BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: <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 />Signed x1 �)l (ti P V," Title/Company <br />Print Name A ' r / �11� I 1� Date <br />SITE MAP IN UNIT IV FILE, ADDRESS <br />WORK PLAN DATED: l(0% <br />Application Accepted <br />DEPARTMENT USE ONLY <br />x--19 A). <br />:6--7 <br />Grout Inspection By IDate Final Inspection <br />Destruction <br />COMMENTS / CONDITIONS: <br />Date <br />2_7- 6o <br />�� cvn.ao-C_'° <br />0 6 85Z <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE <br />PER / SERVICE REQUEST # I CE <br />�IR#� <br />C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit Encroac e$oc <br />EHD 29-02-001 <br />6/22/04 <br />