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• • FILE COPY <br /> D. San Joaquin ounty <br /> Environmental Health Department SITE <br /> y: <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd NOV 2 4 ft IV <br /> CqC/FoR�`P Well Permit Application ENVIRON Iv t -'-` 'it <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ?ERMITISERVICF.S <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 /> /� q' �A ,,C L1 � Assessors <br /> WELL Location 9a I6/ /{� cross Street f Iti l-1. City-L—` aA Zip Parcel# 191 —Z'30 —�Z <br /> PROPET J V�`Q �L, ^ \ 1 r —t`— <br /> Owner 1 QW\T,' CR-1 E y A4ddress f•0•% I tt 5FS�1 CitySCr.�Sd�L"�Zip���'Phone#Ck�� R9I <br /> C-57 Contractor\j �w'S. Address /Do s"', S4. Cit;Lt(4'4o . @(Z�ip5S6~I Lic# 20Ya`iphone# I916� a-y70O <br /> Consultant/Sub Cntr. L JG-Eo lj'lr. Address6-61 LbM.�- d'IWCity K�^� Lic# /vI—Phone#(9116 6' '&3 <br /> GIS Coordinates:X <br /> Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> )(NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> o SOIL BC° ,�-0 /� 0 OVER-BORE, DIAMETER <br /> WELL# r A!!c M1j/N--7 o PRESSURE GROUT <br /> a-Other ,, 11 GROUT SPECIFICATIONS <br /> COMMENTS: L weu �w Cum t.S <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS r� <br /> -PONITORING HOLLOW STEM DIA.OF BOREHOLE F" a MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA: Z _ <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS, NU�TYPE OF CASING: 0 STEEL )XPVC a OTHER: <br /> a VAPOR o MUD ROTARY DEPTH OF GROUT SEAL Z, +. TREMIE TYPE TO BE USED: B AUGERS II HOSE <br /> a AIR SPARGE/OZONE E PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes XNo (NOTE:CQ-"A----)r FREE-FALL DEPTH IS 30') <br /> � <br /> a SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Q;A �` <br /> a OTHER: a O1THER I APPROX.BORING DEPT 0 BOLTED TRAFFIC BOX or STOVE PIPE <br /> SJVIA ,c�f'N�e-TO�RCASING�O� OSK �14(�YE list ape Tica4,Pns i;c�ment se lion) <br /> COMMENTS: <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 alic d that the work will be done in accordance with San Joaquin <br /> County rdin R n 7licable California�Stat�e Laws. ^r <br /> Signed x <br /> Title/Company fit' i `•' �d. � / EN 6r 1 3y C <br /> !,3on"P <br /> � Date Z2— NGV-d' <br /> Print Name �"`�- <br /> D""EPARTMENT/ USE ONLY ��, ( P�- <br /> SITE MAP IN UNIT IV FILE, ADDRESS: e4 ��9'6 <br /> WORK PLAN DATED: ,LIQ ",?'W©-40 <br /> Application Accepted By Date Issued Z/3/D Area O� <br /> Grout Inspection By_ <br /> Dale Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> sR# Dp D560 <br /> do <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encr �t o� <br /> EHD 29-02-001 <br /> 6/22104 <br />