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Qffd'V <br /> 19 gSan Joaquin County v <br /> �������}�, ental Health Department SITE <br /> f:E} , f J le, <br /> venue,3rd Floor,Stockton,CA 95202 MITIGATION <br /> (2� ax:(209)468-3433 Web:www.sjgov.org/ehd <br /> UNIT IV <br /> Well Permit Application <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 <br /> 9-1115.3 and the Standards off,San Joaquin County Environmental Health Department. <br /> WELL Location [U ✓+, Cross Street w t .City ✓ frNl Zip �P rcelM Assessors 1S3-180-0' <br /> PRO <br /> PERtt17 Adf <br /> Ownedress 0 <br /> N (0; 1 500Z <br /> C-57Contractor wto dress%0 Rti (j CnNCity gioLli�>A�ZZipp S6Qp1S�uPahk'o)n1e0d!!1q9l� P—ho�ne�Iv# <br /> - �p <br /> OV <br /> NaTrConsunt/Sub Crtr vir tk ; Pcy. <br /> Lico Phone#_53"%—a)//Z <br /> GIS Coordinates:X Y Township CaRangk Z section <br /> WORK TO BE PERFQ w D• <br /> 0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') DESTRUCTION (choose ty4e below) <br /> 0 SOIL BORING# <br /> OVER-BORE. DIAMETER �l <br /> 0 WELL# PRESSURE GROUT 1 <br /> *Other ROUT SPECIFICATIONS nCltil <br /> COMMENTS: oymhot Mw-17,11q j1)0`l 4u 45-1 V1 Rl SSwr{ 'lo-f �Uh]� I/w, <br /> TYPE OF WEL! INSTALLATION TYPE CONWRMCTION SPECIFIC NS <br /> 0 MONITORING 0 HOLLOW STEM DIA OF BOREHOLE <br /> MULTIPLE CASINGS 0 MULTI-LEVEL UVELL CASING DIA:__�_ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: p STEEL 0 PVC 0 OTHER: <br /> Il VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGEI OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: n OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (if YES,list specifications In comment section) <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�nJa cel,Rules and Regulations,and all applicable Californi//a����Sjta,,te Laws.J <br /> Signedx � � TftWCompany ue0�af— -�f�_5 �nyiibnyl�G+l{ r <br /> Print NameDate Q'�pU�9 <br /> - .. <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FIL ,ADDRESS: bo7 /v- E. S STD <br /> WORK PLAN DATED: /,,0 <br /> D G <br /> Application Accepted Byi( Date Issued- <br /> Grout <br /> 7 <br /> TArea 9q� <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection BLbUDate D <br /> COMMENTS/CONDITION& �V <br /> ACCOUNTING ONLY: AID* FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKS REC'D BY DATE PERMIT/SERVICE REQUEST• INVOICE <br /> 3!5-.62- boSOL 60- rr Z o 0'5-r-F240 <br /> 8 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to Sign pe mit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22104 <br />