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�o qUt" �o .4ian Joaquin County , <br /> _ Envonmental 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.orglehd UNIT IV <br /> r;�oa��P Well Permit Application 2D '��� <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 de r de in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County $tll� tnen. <br /> sn UP;,A f? E. .Assessor <br /> WELT.Location I ba 3 $O.a STAT f-t" Cross Street �� � City $V��� - Zip ��� Parcew <br /> , a <br /> PROPERTY16 STaGr�-T9�f z 9��I Phone# Z°i �i`1�'78� <br /> Owner 1'L��S Address °3.. �D•S S ACVr City P <br /> C-57 Contractor l�£la 1)A­(! �Address L p 8'4X $� City ?Atv"Zip0�03Lie#6C?'A97Phone# ipso 32Z-Z9S-f <br /> Consultant/Sub Cntr J�� (�1L Address 5'7 WA'y���- G City l� Lic# N�' Phone# �ZS ^g am <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ;;!KNEW WELL/BORING (CPT,GEOP ROBE,HYDROPUNCH,HAND-AUGER,OTHER`) p DESTRUCTION (choose type below) <br /> p SOIL BORING# p OVER-BORE. DIAMETER <br /> I -&NELL --rkf"4.fF AS ^'f pPRESSURE GROUT <br /> p`Other GROUT SPECIFICATIONS <br /> a <br /> COMMENT& <br /> 1 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS I/ A <br /> 1 a MONITORING ,:HOLLOW STEM DIA.OF BOREHOLE -17."j]MULTIPLE CASINGS G MULTI-LEVEL WELL CASING DIA: <br /> 11 ;EXTRACTION p AIR HAMMERIDRIVEN CASING THICKNESS $c* !,_ PE OF CASING: []STEEL WVC p OTHER: <br /> I JrVAPOR p MUD ROTARY DEPTH OF GROUT SEAL 8 4444 TREMIE TYPE TO BE USED: �<AUGERS p HOSE <br /> FAIR SPARGE)OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes} p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> p SOIL BORING D HAND AUGER GROUT SPECIFICATIONS 1 i M K,-T— 4A-f-9?, <br /> p OTHER: p OTHER APPROX.BORING DEPTHO 4-1 a LTED TRAFFIC BOX or h STOVE PIPE <br /> 1 CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: ( r <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 /> I County Ordinances, Rules and Regulations,and all applicable California State Laws. <br /> Signed x a'Z-.� TitlelCompany <br /> Print Name { i0 STfrJL�a-� Date 9 �r7-0S� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADD ESS: <br /> WORK PLAN DATED: l D 2�- <br /> fes,, Date Issued -5-11�� d� Area >wl <br /> Application Accepted By (' - — <br /> Grout Inspection By Date Final Inspection By g O Date, <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> 1 ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE} PERMIT I SERVICE REQUEST# INVOICE <br /> 0*01 <br /> C•-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD 29-02-001 <br /> 6122104 <br />