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,oU1. San Joaquin County <br /> Environmental Health Department SITE <br /> r .:. <br /> 600 E.Main Street,Stockton,CA 95202-3024 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.orglehd UNIT IV <br /> Well Permit Application -- -- <br /> �eh yt�h4 NON-REFUNDABLE PERMIT EXPIRES 4 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 9-11 f 5.3 a Standards of San Joaqui- Go my Enviro I Health Department. <br /> WELL Location Ei �' Cross Sir" M 1 ity`' Zip / <br /> PROP TY <br /> Owne Addres / Zp Phone# <br /> + s �v. .t A. ��nar�#sx�i-�8y 72-m <br /> C•57 Contractor�py 02 7A—ddress `I City �� ZiR 2 ic# �,p .-�,,r� <br /> Consunant I Sub Cnlr� r ZNL Addres �' ity�DC,I�I N tJdk Phone#icLJ 9��'I-3 <br /> SoftSvft 100 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ,KNEW WELL I BORING (CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER") 0 DESTRUCTION (choose type beta) <br /> O SOIL BO131piG � BOR <br /> LL <br /> WE # "'t1 f C A 0 PRESSURE GROUT <br /> 'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL- INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORINGHOLLOW STEM DIA.OF SOREHflIE�I 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: Z y� <br /> 0 EXTRACTION 0 AIR F MERIDRNEN CASING THICKNESS '+ // <br /> MTYPE OF CASING: 0 STEEL KPVC B OTHER: MY1 <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Zlr TREMIE TYPE TO BE USED: `,AUGERS I OSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 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 A-0' T 0 BOLTED TRAFFIC BOX or n STOVE PIPE <br /> f <br /> CONDUCTOR CASING PROPOSED (d YES,list specifications In comment section) <br /> COMMENTS: 3 X-b� , ( AWL TayiU n�.W 0,60-4- SG�(_�W� 'l'4un... ( vows ie <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hoFecerltlfy that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> Co ty O loan Rules and Regulatiolts,and all applicable Calltornia Slate Laws. <br /> Signed x » _„_,_Tifie/ConpOanyy�QyQ� _ <br /> Print Na \ bate 0 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ( S210 <br /> WORK PLAN DATED:: '.L I Z S cl <br /> Application Accepted By / l _J i-U '� Date Issued 7 � Area 6'L <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS i CONDITIONS: <br /> AC:COUNnNG ONLY: AID# FAC# <br /> DECODES FEEINFO AMOUNTREMITTED CHECK# RECD BY DATE PERMITISERVICE REQUEST# INVOICE <br /> $R-'� g1 , o Ay z LSA SR# 5�� <br /> C-57 WC„/-WAIVER_, C-57 Letter of Authorization to sign permit _Encroachment doc_ <br /> BHD 29-02-001wcb <br /> 6122104 <br />