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COPYSan Joaquin County ;;` -- FILE <br />Environmental Health DepartmentL-'! E),' SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehif`` ° .01; m? UNIT IV <br />/n5 SMS Well Permit Application ';'•';�'^ ;li`'�',fi= i,.f. �;, <br />11/11 <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 />C, �1 S %irv► Sc�r1 az Assessors <br />WELL Location a o (i i t,'f (J 4 Cross Street � ^n � City ,5 )o, _004 Zip VS -2G -, Parcel# / 7 &6 i <br />PROPERTY <br />Owner (_ A 14rCJc:t Address ii yy o Ove th e id City .S tot (a Zip_ 'S-92) Phone#_ &Sq3 3 (,()6 <br />C-57 Contractor ^Cc c, �/ ,y�� r n Address qS0 Oow e. IZc-4 City )U1a✓-} -%C Z Zip Q VST3 Lic# Y$,i((SPhone# 6926-03-•,s-Qo <br />onsultant Sub Cntr int¢ s Address �),Y?0 (suJcwC%-y0 iCcCityS4(.vav%t"4nLic# Phone# C4(bj674-2000 <br />11-'t.c, <br />GIS Coordinates: X , Y <br />Township, <br />Range Section <br />WORK TO BE PERFORMED: <br />® NEW WELL /ORIN (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) D DESTRUCTION (choose type below) <br />SOIL BORING F✓H S zH S 6 d! l=vh S, v s 13 o f F /_,n t 5 z4-1 144 o(_ 0 OVER -BORE. DIAMETER <br />0 WELL # FA,0 -Lt ii`4o D PRESSURE GROUT <br />D *Other GROUT SPECIFICATIONS <br />COMMENTS: haLA d 4,1Ce,.1S a.�_S~_ hOLt'r:w-S�ewi <br />TYPE OF WELL t02 <br />CONSTRUCTION SPECIFICATIONS; <br />D MONITORING EM DIA. OF BOREHOLE_S� 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: IV,4_ <br />D EXTRACTION DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL 0 PVC D OTHER: _ <br />D VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL (0 --?rZ TREMIE TYPE TO BE USED: D AUGERS 0 HOSE <br />A A / OZONE P or CPT GROUT SEAL PUMPED: D Yes D No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30 ) <br />0 SOIL BO HAND AUGE GROUT SPECIFICATIONS <br />OTHER: 0 OTHER APPROX. BORING DEPTH TY0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />?? r CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: IJO:'� Vl Olcj 04(v <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 x -rpt ,/' Title/Company %c i r "4 t,3 4- <br />Print Name 6-a (i cyS Date 1 Ek b o 7 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS <br />WORK PLAN DATED: ZSr <br />Application Accepted <br />2957- CAS-� <br />�0 Area 66 �54 <br />Grout Inspection By DIRe Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS ! CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />Zgo� <br />1W <br />P0 o 6 Z <br />3-20 <br />SR# p,J50 <br />C-57 ✓ WC ✓WAIVER_ C-57 Letter of Authorization to sign permit ✓ Encroachment doc�fq <br />EHD 29-02-001 <br />622/04 <br />