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an Jo <br /> aquin County <br /> :y Envir mental Health Departure <br /> Imo:: SITE <br /> 304 East Weber Avenue, 3rd Floor Stockton CA 9i t- �I <br /> { • ' (209) 468-3449 Fax: (209 468-3433 ^ I i k.r i�....,, .MITIGATION <br /> ) Web: www. <br /> Well Permit t UNIT IV <br /> Application <br /> NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DRTE <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application ismade in compliance with S <br /> Joa in County Development Title,Chapter 9-1116.3 and the Standards of San Joaquin County Environmentaf Health Department. <br /> r0 a F-I U f v ' Dcl I S ►c Ul { I ! an <br /> MfEttL(cation Cross Street �' I�u Cit), L 6 _t Zi ��Zlf Assessors <br /> PROPERTY p —..�2 Parcel# O -D 6 -Z2 <br /> Owner �Qa v" <br /> q _Address �7 U T N116Uisli L <br /> t�_ f 'City Zip l�2 V2�hone# <br /> C-57 Contractor R S 1 #df'i >7� Address �-� �° Ca 5t S&eCC- <br /> City- -`lou-Z Zipq5�� <br /> Consultant/841; r rCC 6f-0 Lvze T <br /> ic# �i0Z33 <br /> � � i8Z�Z(f <br /> . CAddress � � { C#y 0ek-lr57Lic#6 <br /> 71;?-2-`Phone# 530-758-612p <br /> GIS Coordinates:X Y r p /_ <br /> Township `L Range & 9 <br /> Tp BE PE _ <br /> Section <br /> 2- <br /> 1301 (CPT, EOPR YDROPUNCH,HAND-AUGER,OTHER* <br /> 9 SOIL 80 # t 2 ) D DESTRUCTION (choose type below) <br /> Q WELL# Q OVER-BORE. DIAMETER <br /> Q "Other Q PRESSURE GROUT <br /> COMMENTS: A i-Xi rrw� n4 3 j1c, oIjt'h GROUT SPECIFICATIONS <br /> C���� l�v�h���•�Cc,r=([r�r �� �gr�u5� �'e�e� �i:cr�t�. -{�,;,���� <br /> TYPAL INSTAL IQN TYP CONSTR"rTirWiSPECIFlC�TIONS <br /> 0 MONITORING 11 HOLLOW STEM DIA.OF BOREHOLE <br /> a EXTRACTION Q Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> AIR HAMMER/DRIVEN CASING THICKNESS <br /> 0 VAPOR TYPE OF CASING: Q STEEL Q PVC Q OTHER; <br /> Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED; <br /> Q AIR SPARGEI OZONE 0 PUSH POINT(GP or CPT}GROUT SEAL PUMPED: [)AUGERS Q HDSE <br /> 'JSOIL BORING Q HAND AUGQ Yes Q No (NATE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> AUGER GROUT SPECIFICATIONS <br /> 1]OTHER: __-Q OTHER APPROX.BORING DEPTH <br /> ffi Q BOLTED TRAFFIC 80X or Q STOVE PIPE <br /> COMMENTS: lQd L itit S �n SW�t � CONDUCTOR CASING PROPOSED (if YES, lists ecificatians in comment section) <br /> �a � r,wti.a(w�- ���, � <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMIT <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. S. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ord' ces, Rules and Regulations, and all applicable California State Laws. <br /> Signed x � �y�]�. <br /> - 7G�- Title/Company ' 5G(&" 'L I I-C ar0i. j_ <br /> Print Name <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, A DRESS: 1 07� W, /Zi Ee'L. <br /> WORK PLAN DATED: / ///a/0 7 <br /> CC.v <br /> Application Accepted By � <br /> Grout Inspection By / Date Issued 1(��07 Area <br /> Date �'� m i Final Inspection By <br /> Destruction inspection By Date <br /> Date <br /> COMMENTS/CONDITIONS: '115 <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc <br /> EHD 29-02-001 <br /> 6/22104 <br />