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�, C V San Joaquin County ' <br /> 304 <br /> Environmental Health Department. SITE <br /> Avenue,3rd Floor;Stockton;CA 95202 MITIGATION <br /> 8-3449 Fax: (209)468-3433 Web: wwwa ov.or ehd <br /> y�iE `� jg g/ UNIT IV <br /> t;�1�I� OCEt Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is here made to San Joaquin County for,App by aq ty 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 toff San Joaquin County Environmental Health Department. <br /> WELL Location +a V0 4 S�r td Cross Street Of City 1�1 Zip V oS�_PaSoeH4r_I53-f$U D y <br /> PROPE131Y1 I r� n f CC <br /> Owner_ t� (d''ML{ FJ Address.PIa�i &,X 1,�Z City�l � �tC1 Zip 1595 I Phone# 4j <br /> C-57 Contractor Uk +ttir : AddressJ.W�d tI(7 l &1;�: City :C� uyu zi (o <br /> p 57V Lim f7 Z90 Phene X38 11 9 <br /> Consultant/Sub Cntr�`�w�ll5 Fvlviloomkjo. Address (a laGr>r)17 bf c y` to Pllfik . :Phone#5361-6J. <br /> GIS Coordinates:X Y Township Range Section <br /> i <br /> 1=Y11 WELL1 BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> R SOIL BORING ST 0 OVER-BORE. DIAMETER <br /> # 0 PRESSURE GROUT <br /> 'other . GROUT SPECIFICATIONS <br /> COMMENTS: p� <br /> TYPE OF WELL INSTALLATION TYPE CONMUCTION SPECIFICATIONS /I <br /> )(MONITORfNG HOLLOW STEM DIA OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:Z <br /> 0 EXTRACTION 0 AIR-HAMMIER/DRIVEN CASING THICKNESS()TYPE OF CASING: 0 STEEL �WVC 0 OTHER: 4 <br /> Q VAPOR 0 MUD ROTARY DEPTH OF GROUT SEA t TREMIE TYPE TO BE USED: AUGERSSE <br /> Ye <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED:;. s 0 No ("NOTE: MAXIMUM FREE-FALL DEPTHV20) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS (prva�iwr _ <br /> 0 OTHER: I7 OTHER APPROX.BORING 6EPTH_�s r �OLTED TRAFFIC BOX or 0 STOVEPIPE <br /> CONDUCTOR CASING PROPOSED MO (if YES,list specifications in comment section) <br /> 'COMMENTS-.— <br /> NOTE: <br /> COMMENTS:NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I havo prepared this application and that the work.will be done in accordance with San Joaquin <br /> County O inna,�nces, Rules and Regulations,and all applicable�CalifomiaLSStaPe Laws. /J -� r <br /> Signed (�1t �f/1/� Title/Company S�r�'v5 .,lvifv�_/n�v1 !!Yl{: _l�jE'd>'o5 s�) <br /> Print Name >ii f Date 0I <br /> DEPARTMENT;USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS:—/0 3 PJ- Z- -7 A- , <br /> WORK PLAN DATED: ' <br /> Application Accepted By. Date Issued !! z �v G <br /> Grout Inspection By. Date 12f D Final Inspection By Date <br /> Destruction inspection.By Date <br /> COMMENTS/CONDITIONS. <br /> [ACCOUNTING ONLY; AID# FAC# <br /> CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 0 l 9 9.O—V. 9� eP 1(116-7 If iZ/y o sR <br /> C-57_ WC WAIVER,,, C-57 Letter of Authorization to sign permit_Encroachment docm— <br /> EHD 29-02-041 <br /> 6l22M4 <br />