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FILE COPY <br /> J <br /> oPgU-1 Y San Joaquin Countya <br /> SA <br /> Ynvironmental Health Department SITE <br /> w < /tf3GNtLt Weber Avenue, 3rd Floor,Stockton, CA 95202 \n 1 MITIGATION <br /> (IfiMO }449 Fax: (209)468-3433 Web: wwwsjgov.org/ehd � '�1 UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED � \ "" <br /> 15 <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 n--l—""n'T'ti` rhonrer 0-1 AIA I�..n the Standards of San Joaquin County Environmental Health Department. <br /> �po� /n'/ / Assessors I--1 <br /> WELL Location-�6 a l� - - ross Street 1.�, Zip .Jd Parcel# <br /> PROPERTjt ,,,/ `/ y�f // :v5sl ��� 1)4 <br /> Owner ( r T`// 1PT 'e✓/ ✓�`I'I Address 0 7 /� .G�ciity / >Zip ]y/hone# g �.�1 2 <br /> C.57 Contractor,& () //�1 �2��0( Address lZyf EF 14el- City iF�IL°`vrZip !.S//64 Phone#1sl�!/y- 3`//73 <br /> Consultant/Sub Cnt,4 �4nar ,,� Address Z�C� 7///eIYFCily S/ �-�✓ Lic# Phone#' t�e/`V/32/� <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL 1 BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER*) g DESTRUCTION (choose type below) <br /> Q SOIL BORING# a OVER-BORE. DIAMETER <br /> WELL# — { ' I ' —�/� nen/9� rZ, 13 a PRESSURE GROUT <br /> I 'Other / �j GROUT SPECIFICATIONS <br /> COMMENTS: �W/7—/� �!' � u L�� // /l""✓ (/ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> /1tONITORING `¢HOLLOW STEM DIA.OF BOREHOLE,Q� 0 MULTIPLE CASINGS o MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION /a AIR HAMMER/DRIVEN CASING THICKNESS !Li D TYPE OF CASING: E STEEL OPVC a OTHER: <br /> Q VAPOR O MUD ROTARY DEPTH OF GROUT SEAL . TREMIE TYPE TO BE USED: UGERS 0 HOSE <br /> a AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0o (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING a HAND AUGER GROUT SPECIFICATIONS/yob /O-vn th. -7)` <br /> a OTHER: a OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: (,moi A i/7 /2/ Z 7-� y 3---� 22 e— / y4 j� y � ? <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 and Regulations,and all applicable California State Laws. / 7 <br /> Signed x Title/Company <br /> Print Name J CG G ec�T Dale 3// <br /> DEPARTMENT USE ONLY <br /> l <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 000p0c) �trti GC�try lf�D�� <br /> WORK PLAN DATED: /��6 QQ'' <br /> Application Accepted By Date Issued 5- 16 <br /> � 5 Area <br /> Grout Inspection By Date Final Inspection By Dale <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> WACCOUNTINGNLY: AID# FAC#E INFO AMOUNT REMITTED CHECK# R C'D Y DAT PERMIT 1 SERVICE REQUEST# INVOICE <br /> wZSR#- _ =WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc � �/ulltt�9�� <br /> EHD 29-02-001 <br /> 6/22104 <br />