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San Joaquin County <br /> �i Envirt'..'-fimental 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.org/ehd UNIT I1/ <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUqag6-kUG <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. Th' a 1' MA INILmpliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmenfa MtNV <br /> / g DE ssessors <br /> WELL Location 130 C._I.IANN��. _ Cross Street I�[, G(�01 City_ CAE Zp , Parcel# 1,J11-2-70--if 0 <br /> PROP TY <br /> Owner W1r1DnIt��4PF� -rWKP _Address_ I S. �� Z Aq]r City DC1L7U4Zip Phone# "T(ofa'ft� <br /> spv/-rG83gG� <br /> C-57 Contractor F i .5 c h D i l!i aA Address 3 9 9 sh eri`S P14e e city- yA",e Zip ft c# Phone# -20 Z-35-70 <br /> Consultant/Sub Cntr UN�rAWtt TJ�Cd'in& Address/ W �_ 7�b�ic# � Phone#Z�f 518 <br /> -0 <br /> GIS Codrbina es:X� 3faa5�. {v Y Z 1714-Zt 0 Township I Range �C-- Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL 1 BORING (CP"2��-- <br /> HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> SOIL BORING# a OVER-BORE. DIAMETER <br /> WELL# - COPY GROUT SPECF CATIONS <br /> PRESSURE GROUT <br /> *Other <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> EXTRACTION j AIR HAMMER $� CASING THICKNESS TYPE OF CASING: Q STEEL a PVC a OTHER: <br /> (l VAPOR G MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS a HOSE <br /> Q AIR SPARGE/OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED: g Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> i SOILiBORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> p OTHER:_0 OTHER APPROX.BORING DEPTH g BOLTED TRAFFIC BOX or [I 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 /> hereby certify that I have prepareiij this application and that the work will be done in accordance with San Joaquin <br /> C4d, <br /> rdinances, Rules an g tions, and all applicable California State Laws. <br /> Si TitlelCompanyIeI& <br /> LPrDate <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 730 Ch I tHeee-F <br /> WORK PLAN DATED: 2 G <br /> Application Accepted By Y ick L 'L Date Issued Z 3 UG Area at 579 <br /> Grout Inspection By72:j,� y Date `t Z Final Inspection By � ate 9 -L9 6 <br /> Destruction Inspection By Date el <br /> COMMENTS!CONDITIONS: rz- S S S13- - S&lo sig-)f' <br /> FACCbUNTING ONLY: AiD# F <br /> CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> Ar <br /> 03 X85 :374 SR# -© 0+17q`f-5 <br /> C-57_ W(_-WAIVER- C-57 Letter of Authorization to sign permit Encroachment doc_ <br /> EHD 29-02-001 <br /> 622!04 <br />