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1 <br /> o San Joaquin County no <br /> Environmental Health Department HECE � -'SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 9520EF MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sigov.Org/eff—q '1,(44 <br /> rR0 ENI�pq(�ONMENa ITUNITIV <br /> Well Permit Application /V1 4 <br /> PER1gMLTJSEES <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/D�epartme`n_t. <br /> WELL Location_ 22 '�00 UA-4'f A'4�t AJ ,Cross Street l2!' /A'✓F city /} GyQ� Zip 7�y17t�Pamel#Assessors "LSZO70oZ <br /> PROP <br /> Owner7W!!'+ET/1Cl-O�rfyj(raA7ss ,157049 C*f/S,yAJ I&City '�AtV �PI"37�0 Pho�n/e# ;2a-;2a- �3 �q <br /> C-57 Contractor_ 6/26$6- jaQkyA/bAddress 9V&60C_ RD- CIb&_ EZZip S3"Lic#y�o�G5"Phone# <br /> onsultant/Sub CntrV95S Coe/! AadreW87n 64*rAW avKr&'e1iy Sym Lim Phone#_`//96-619-2000 <br /> GIS Coordinates:X ,Y ,Townshi <br /> P Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPVNCH,HAND-AUGER,OTHER`) g DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 44l f!O- ( ril�1 <br /> 0 WELL# 0 OVER-BORE. DIAMETER <br /> O'Other 0 PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: SE�ATYAC,yEy lny qt/p wfu.TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS y xk vR�- Qf <br /> 'MONITORING OLLOW STEM DIA.OF BOREHOLE '_ <br /> �_ IItMULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA � <br /> 0 EXTRACTION p AIR HAMMERIDRIVEN CASING THICKNESS S OTYPE OF CASING: p STEEL PVC p OTHER: o <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ✓AAW-< TREMIE TYPE TO BE USED: II <br /> /0'e- <br /> 0 AUGERS 0 HOSE Y /A'C <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: <br /> p SOIL BORING Wes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 HAND AUGER GROUT SPECIFICATIONS 41_1A111~ aq�0 v13 at i,�,�•/„!X <br /> 0 OTHER: n OTHER APPROX.BORING DEPTH /LD fro 0 BOLTED TRAFFIC BOX orSTOVE PIPE <br /> CONDUCTOR CASING PROPOSED— it'ro ,list specifications in comment section) <br /> COMMENTS: (f YESlii <br /> e <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 Ordinances, Rules <br /> sstand Regulations, and all applicable California State Laws. f <br /> Signed x A n/ vim' Title/Company <br /> Print Name /�lC/f4QD y'/�,v Jjy <br /> to <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: oZS ?00 t a/r o�_RSL <br /> WORK PLAN DATED::Appl ,1 <br /> GroutInspection BAccepted ey LH-'[t wr.S�-(� , Dale Issued a (0 <br /> Grout Inspection B Ellyn .- c Area--�--.-�— <br /> DaleD ) Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: CVREA-0-L ek <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMR/SERVICE REQUEST# INVOICE <br /> �`Iol q " y ' S4�� bq /SIL 3 0 SR# DO`` 677 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD 29-02-001 <br /> 622/04 <br />