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In Joaquin County <br /> EnvirVmentaZ Health De artment <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 SITE <br /> (209)468-3449 Fax:(209)468-3433 Web: www.sjg0v.org/ehd MITIGATION <br /> Well Permit Application UNIT IV <br /> NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> Joaquin Co is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application fs m <br /> Joaquin County Development Title,Chapter 9-1915.3 and the Standards of San Joaquin County Environmental Health Department. <br /> made In compliance with San <br /> WELL Location I j <br /> Cross Street City Assesso <br /> PROPER Zp ` Parcel#�2Q—110-03 <br /> Owner Address $] ; <br /> Cdy Zup Phone# kr1/S <br /> Consultant/Sub Cntr <br /> C-6T Contractor t Address <br /> Cd-�Zlpr!? <br /> Address i,,, C. <br /> GIS Coordinates:X Lf Phon r <br /> Y ,Township <br /> Range Section <br /> Q NEW WELL/BORING (CPT,GEOPROBE,I.IYDROPUNCH,HAND-AUGER,OTHER") E3TRUCTION ch <br /> 0 SOIL BORING ( oose be <br /> 0 WELL# OVER-BORE. DIAMETER Ir <br /> a"�► (I PRESSURE GROUT <br /> COMMENTS: GROUT SPECIFICATIONS <br /> INSTALL&MN DT <br /> 0 MONITORING 0 HOLLOW STEM DIA OF BOREHOLE <br /> 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA; <br /> 4 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS <br /> 0 VAPOR 0 MUD ROTARY ---TYPE OF CASING: �STEEL 0 PVC !1 OTHER: <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT GP or C DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 11 AUGERS _j'HOSE <br /> ( P'T)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH S 30 <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER: OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> COMMENTS: <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications In comment section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> - <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ord7M7;7 <br /> ulations,and all applicable California State Laws. <br /> Si9nedX Title/Company_ LfX15f" _ <br /> Print Name t Jana Date! 1 10105 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT N FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued I Za Area <br /> Grout Inspection By Date final in <br /> Destruction Inspection By Inspection By Date <br /> D <br /> CQMtTS!CONDITIONS: <br /> ACCOUNTING ONLY: AID# F 4 W7 <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKS REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> isozu <br /> 3 3 23 13 <br /> 00 sR# �-S <br /> C-57= WC -WAIVER C-57 Letter of Aut izat' sign permit Encroachment doc <br /> EM 29-02-001 <br /> 6C2M <br />