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�QrJrN. an Joaquin County <br /> Enviro mental Health Department SITE <br /> nooMITIGATION <br /> MAP, a � <br /> �� 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MAP,. <br /> • : (209)468-3449 Fax: (209)468-3433 Web: www.sjgoV.org/ehd UNIT IV <br /> Well Permit Application P01� ! '3'ER VIG E 5 <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 /> 2 t QI ZFJta <br /> Assessors <br /> -9-5 <br /> WELL Location 2 ��\ W Crass Street V City ZAP <br /> PROPELT <br /> RTY K S ��C 7A"�L -r1 <br /> Owner �JV6-4x3 q Address rr,'Oe-q' O�cA tcity f�'^ Zip �5�'$hone `1A 9`�')`"01 �� <br /> C-57 Coniractor��y��'�1�Yti> 17Wt6yIAddress 3AB Q(r°i ',y T�LCity�l[t�FnM1f►��Zip ((�S5rJic#�y4�! Phone#SD9-�} �-j3�1�7 <br /> Consultant Iddress�� Wt`ytcQt�(czg D> �City �le# r PhoneIb "� <br /> GIS Coordinates:X Y Township_ Range_ LD tJ Section z <br /> WORK TO BE PERFORMED: <br /> XIEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER`) o DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> ` HELL# 0 PRESSURE GROUT <br /> O'Other - GROUT SPECIFICATIONS <br />` COMMENTS: 7,. (9* S <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 /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESSj6Wi4 4'0 TYPE OF CASING: 0 STEELPVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL -71D r TREMIE TYPE TO BE USED: XAUGERS 0 HOSE <br /> 0 AIR SPARGEI OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes XNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL_BORING 0 HAND AUGER GROUT SPECIFICATIONS 'V1e-�d C�e o- e <br /> 0 OTHER:_n OTHER APPROX.BORING DEPTH_ )% ' )KBOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> � 'r, CONDUCTOR CASING PROPOSED la D (if YES,list specifi6ations in comment section) <br /> COMMENTS: �, CL+a nn& j Weiv, `tu AZO-r,=,n66 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRE© FOR INSPECTIONS. <br /> I hereby c ify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> CountyOr nances, R les and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company �V.lclt l-w[Zig �64Vwk vR KE)Jr fN C. <br /> IJ I <br /> Print Name t{. - « Date Z <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS:—'):?-5 5 A e c�>,>vl6- moo, ^ <br /> WORK PLAN DATED: S l'1 101 Lmw1't-1 IT-(og (mow-'� UW-'k &/w-S <br /> Application Accepted By Date Issued -wVl� • Area 34 Lt <br /> Grout Inspection By Date Final Inspection By Date o <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> �Sul �q.00 <br /> z 3 ?? J �"3-oZ 3.�,, ag SR# V o 36r, i <br /> C-57-[ WC__�f -WAIVER C-57 Letter of Authorization to sign permitEncroachment doc_ <br /> EHD 29-02-001 <br /> T 5122104 <br />