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too RC <br /> San Joaquin County <br /> Environmental Health Department lki _ SITE <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA X405 <br /> � �FNT MITIGATION <br /> (209)468-3449 Fax:(209)468-3433 Web:www.sjgo- # HEALTH UNIT IV <br /> Well Permit Application TISERVICES <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,Chaptler 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. ) �n <br /> WELL Location Al0 1&-5—r CbVW'k •��L rossStreet S r�ity-,,! �' Zip-��Pa�rce Assessors <br /> PROPERTY � T y� T <br /> Owner T�C �vru1Cl rot!! Address 2,n Uit _k Off) Ur City.�'D ZipQazKPhone <br /> C-67 Contractor C/ Address= N, i&uz &U-- cityy�gcip 9u9/�LicJl�� Phone�T,a l l� G'T� R <br /> Consultant/Sub Cntr C T GG AddresssVl old 'CiZewLm ic# Phones 70� <br /> 5vir� <br /> GIS Coordinates:X 'y Township Range Section <br /> WORK TO BE PERFORMED: <br /> jkNEW WELL/BORING (CPT,GEOPROB-, ROPUNCH,HANp;�,UGEF,OTHER*) Q DESTRUCTION (choose type below) <br /> 31 SOIL BORING#� —J Z��rcc7 f'r/SI{Does p OVER-BORE. DIAMETER <br /> Q WELL Q PRESSURE GROUT <br /> Q`Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA: _ <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS_ VA TYPE OF CASING: 0 STEEL Q PVC 0 OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL—__2,Q_TREMIE TYPE TO BE USED: 0 AUGERS Q HOSE <br /> Q AIR SPARGEI OZONE #PUSH POINT(GP or CPT)GROUT SEAL PUMPED: j Yes Q No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> 'SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS ��Cp1t y <br /> Q OTHER: fl OTHER APPROX.BORING DEPTH���_p BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED AID (f 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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi antes,RuIV and R tatiens;and all applicable California State Laws. <br /> Signedx / 9C4 4/. Titie/Company ^ <br /> 00, <br /> Print Nam a- LTl(x Date O <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: A 1 A <br /> /(� ,, t <br /> Application Accepted BykZ4 ` Date Issued 12 / i �- Area <br /> Grout Inspection By to (zAaE Final Inspection By yftoto <br /> Destruction I Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID* y1kV S FAC# 7 Zo4*i..e . <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST i INVOICE <br /> g01 8 Q.00 i 3 q/ SR# 4S1 .S <br /> C-57 WC=WAIVER C-57 Letter of Autho at' n o sign permit Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22104 <br />