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u��ui� cucu ic. ii cu�4oaaY� II JO$ U>tn Gnu rHUa uc uru <br /> y,. o q county <br /> a Environmental 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 /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES t 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 /> WELL Location / '�' Cross Street ���)/ Assessors <br /> City Zip Parcel# <br /> PROPERTY / <br /> Owner [9' Il/I Address v�Md�g/p for City��`Zp gX-2&Phone#,j7i3, �ylp'C' <br /> C-57 Contrador +�'r! Address zip r�Li q62 <br /> Z' J <br /> Consultant/Sub Cntr RIJf/' ddress 37�j/y//� Crt��Lic# 2�G�z'J Phone# <br /> GIS Coordinates:X_ ,Y.,Townshl <br /> P Range_ �Section <br /> WORK TO BE PERFORMED: <br /> d NEW WELL/BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER'S p DESTRUCTION (Choose type below) <br /> WELL#ORS/# - dW-60OVER-BORE. DIAMETER <br /> ✓� C1luS <br /> 'Other p PRESSURE GROUT <br /> r� GROUT SPECIFICATIONS <br /> COMMENTS:/ 1. irrr -�AfSftl/�—Zi <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING AHOLLOW STEM DIA-OF BOREHOLE 0 MULTIPLE CASINGS p MULTI-LEVEL WELL CASING DIA:z <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS <br /> 0 VAPOR ! —TYpE OF CASING: 0 STEEL p PVC,yy''p pYI IER: <br /> 0 MUD ROTARY DEPTH OF GROUT SEAL 4291, 6S-/TREMIE TYPE TO BE USED; &UGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: JjYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS PeWr i) 10KeAJ1- <br /> OTHERQt}dt 0 OTHER APPROX.BORING DEPTH /G1/ -��, <br /> r.�r���!_ BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> �y,� CONDUCTOR CASING PROPOSED /V0 (if YES,list specifications in comment section) <br /> COMMENTS: O'�DNE'/N7--&Z rggi /y�{ /M TActM7o7rt/ <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 Ordip�nc ,Rules and Re aEfens�andall pplicable California State Laws, y / <br /> Signed x r / Y Trts]Company >p- / 1 Z tiesJf'91/IY//!7jWA71 Ly <br /> arint Name IiT'� ✓ J <br /> Date 21-7-9 <br /> DEPARTMENT USE ONLY <br /> iITE MAP IN UNIT IV FILE,ADDRESS: <br /> YORK PLAN DATED; J. 13M-161 0 S <br /> ,pplication Accepted By Date Issued <br /> ;rout Inspection Qy Are q7 <br /> Date Final Inspection By Date <br /> lestmction Inspection By Date <br /> OMMENTS/CONDITIONS: CUIQtwJQt4 L1• <br /> ACCOUNTING ONLY: Alp# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE <br /> PERMIT!SERVICE REQUEST# INVOICE <br /> ;2-`Io1 8y j,5 a'�779 1w- 7/1 AI SR# vUV3761 <br /> -57— WC -WAIVER„ C-57 Letter of Authorization tc Sign permit <br /> FID 29.02-001 Encroachment doc_ <br /> 22/Od <br />