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- San Joaquin ountYMEN FILE C <br /> Environmental-Health Department (��� SITE <br /> Q 2 V'� ITIGATION <br /> 304 Fast Weber Avenue, 3rd Floor Stockton CA 95202 d ; <br /> (209)46$-3449 Fax: (209)46$-3433 Web: www.sjgov.org/ehi 4�y GoutITAJNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED � Tki pPA <br /> I <br /> Application is hereby made to San Joaquin County for a permit to construct andlor 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 /> 2009Assessors .r oOtJ, I <br /> WELL Location �� _ Cross Street /�E City � iuN Zip �o Parcel# C` S �� <br /> I <br /> PROPEF�TYw, °Io yl�N�1 �v �y �l �r®.J p9S?42 24q <br /> Owner (�/6y O�sTOG4TdWV Address Ci Zi Phone# <br /> C-57 Contractor SP�G'72y/yJ �jC. Address �N��GI »7 d/1 City S?�G,�`!O/l/Zip9SLic#517 Phone#p � <br /> Consultant!Sub Cntr H/GG ��}/ / Address � City� ic#G S 07 Phone# !la/o 729 Sf07 <br /> GIS Coordinates:X Y Township Range Section <br /> W RK TO BE PERFORMED: <br /> NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") d DESTRUCTION (choose type below) <br /> [],SOIL BORING# []OVER-BORE. DIAMETER <br /> WELL# rM W 7 9 j t� ,—A—W-77 V-0 1]PRESSURE GROUT ; <br /> []'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS i N <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE []MULTIPLE CASINGS []MULTI-LEVEL/WELL CASING DIA: <br /> o EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS SGH 11/0 TYE OF CASING: aSTEEL PVC [IOTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL d" 71 TREMIE TYPE TO BE U ED: UGERS p HOSE I <br /> []AIR SPARGE!OZONE a PUSH POINT(GP or CPT)GROUT SEAL_PUMPED: Yes �gNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30 ) <br /> Q SOIL BORING []HAND AUGER GROUT SPECIFICATIONS_Jam'70�ejqAJH, 0 Peltg <br /> __1_-/ ery <br /> []OTHER: []OTHER APPROX.BORING DEPTH 55 gi-kT *OLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 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 Oi Y./ Title/Company_ <br /> Print Name '`< iVG,4�Wf1� - Date <br /> DEPARTMENT USE ONLY �5*Q3 <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 1 15 /U. Nim b <br /> WORK PLAN DATED: l'S' <br /> Application Accepted By Date Issued �" Z 3 Area 46 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: —5: <br /> ACCOUNTING ONLY: AID# FAC# <br /> I <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> SR# �} <br /> C-57 J WC_-WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc �3 <br /> EIiD29-02-001 dG 0 . oz,Uj <br /> 6122104 <br />