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San Joaquin County <br /> Envi*mental 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 IV <br /> c P <br /> Well Permit Application <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 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 /> Assessors <br /> WELL Location -14kl, Cross Street City_Lol)/ Zip Parcel# <br /> PROPERTY / Z <br /> Owner >'r /N Address a075M�MM61£�/HIv� L.lyd city�Zip g 2&Phone#✓, 31 0152/1- <br /> C-57 Contractor r�'rZ 110 Address��/rraK(" ,- / CityZip -I5 Li / honey#�T��7•fes//9UyU <br /> Consultant/Sub Cntr VU . Address_/�37.9/Qtd/� Cit Lic# 2'U7Z7 Phone# We7'1m6 <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> WELL# /1/!/4 E-/,JS P)IJJ- ,ULv-S-�OLr!-6 a PRESSURE GROUT <br /> 'OtherGROUT SPECIFICATIONS <br /> COMMENTS:M-1 /-s -nr1Gn—'//A1SfR'&*6� , <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 'HOLLOW STEM DIA.OF BOREHOLES- a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 644 U TYPE OF CASING: 0 STEEL 0 PVC "G OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALA & <br /> fR4*. 6S- /TREMIE TYPE TO BE USED: UGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ft Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 1^7VR74hNp LE Wel J r <br /> OTHER:(I1 VL 0 OTHER APPROX.BORING DEPTH IdA/-70 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED A0 <br /> �j (if YES,list specifications in comment section) <br /> COMMENTS: 19**Jt- /Ny-tL WOU Alac /NSTAt 4zz.-o/ <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 /> County Ordince , Rules and Re ations, and all applicable California StateLaws. <br /> n <br /> Signedx ��/t./1' Title/Company 1//d� //7UU.1///CPGf (7�U7✓I YUY//7'///77K .t� <br /> Print Name �7Pill✓U.l✓ Date 717—&/J� <br /> V DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATEQ:I. l A-. ._ fref1i �rva-P 7 P OS- <br /> Application Accepted By K Date Issued M,b s- Area <br /> Grout Inspection By Date / !0 Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: CU12tJ G7.u'j e, - f}. S <br /> ACCOUNTING ONLY: AID# FAC# ' <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> a'?ol 85 y5 �a��q r� ��l o,r SR# Ul) V376 / <br /> C-57_ WC---WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 622/04 <br />