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oq�Y'". C San Joaquin County <br /> l� <br /> Envi"mental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> • (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> 4<ri b� Well Permit Application <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 /> 2Z5 y q �! �L Assessors <br /> WELL LooccatitionpQ� O Cross Str6et C/�µ` IA city�1 —Zip � Parcel# !oQ'O3O <br /> PROPERfiS( K / 5�'��C z�� n <br /> Owner h�i'D _Address �` ,City `�x+ .Zip �C120%one 9`+1— a1-o <br /> C-57 Contractor�t '`�6tiAo)jynevd-Address p 0 ICE 1��City�ICLt��W►C�Zip_{9� ic#��{477 Phone#g�9�4� 1315 <br /> Consultant/�trb-Grsk Oy1&��CMlV1 11- ddress��I Wiytr�t7(d+�� City a✓uc�o �1 Phonedb -A <br /> GIS Coordinates:X Y Township AI _- __Range �� Section �Z <br /> WORK TO BE PERFORMED: <br /> NEW WELL 1 BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER") 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER�� <br />' WELL# IAVJ� k�"" tZ-L Sr.r.+citi.�� 'Ss=.5-5' bS�r 0 PRESSURE GROUT <br /> 0`Other GROUT SPECIFICATIONS <br /> COMMENTS: W±iU:_ �CY �` <br /> } <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS�� TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 136 TREMiE TYPE TO BE USED: j�AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes *No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS M& CeVue--v !j <br /> 0 OTHER:_O OTHER APPROX..BORING DEPTH r-/5 / BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> ff CONDUCTOR CASING PROPOSED �fl (if YES,list specifications in comment section) <br /> COMMENTS: L!� t�Gt� t:Ovi.1 � r�.Cis�rczlM�r• -. -- <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San .Joaquin <br /> " County Oqdinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x "' Irk , Title/Company <br /> Print Name 16A UL, ��-�'�ctL�`' Date Y 6 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 7--L <br /> WORK PLAN DATED: Sk"110-1 Cwkw't.o) toigzl o (, uuw- ( utit..j•l'Z ___ <br /> ` Application Accepted By A..rw,.FC Date Issued -s "tA 0-� Area <br /> Grout Inspection By Date Final Inspection By Date 3,1 L 9 <br /> Destruction Inspection By Date <br /> i COMMENTS I CONDITIONS: <br /> y <br /> EACCOUNTING ONLY: AID# FAC# <br /> FEEINFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT f SERVICE REQUEST# INVOICE <br /> sa-w SR# o <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit—Encroachment doc__._ <br /> EHD 29-02-001 <br /> 5/22104 <br />