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agD !N San Joaquin County <br /> r o coi Environmental Health Department SITE <br /> :< 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> . 41 (209) 468-3449 Fax: (209) 468-3433 Web : www . e]t1 UNIT IV <br /> Lo Pio 4 19 <br /> Well Permit Application <br /> Sk 'It J ;: UIJIN COUNTY <br /> NON-REFUNDABLE PERMIT EXPIRES 7 YEAR FROM DATE} PR) NNENT A L <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work) 6s"sdr Rdd. [*R 4pil'Atlf-fsTmade in compliance with San <br /> Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. ��© �� <br /> Assessors � <br /> WELL Location I Q O 1 Sm..g1'1 (•• LfOrad.� Cross Street City ��7JcyXY\ Zip ��Olo Parcel# ,J <br /> PROPEnRTTY_� " " c A, n - n Com . , !, <br /> Owner f 6.r" � Address j901 JOW 1) ZjbbWOIUCib 1 (yi1/6.,A1M Zipl2L(a Phone# 2� i $ 365 <br /> C-57Contractor�'(e )rLe AddresQGO 1}p ,Ne No, City Zip "1gS53Lic# b40 Phone# R3�-313 5Wb <br /> Consultant / Sub Cnlr PF &1G _ Address_ $ 37 tilnA,w Cit)/t j2Lic#(o�07.3� Phone#.;1(fI `1b7 " 16TIo <br /> GIS Coordinates: X Y , Township Range Section <br /> WORK TO BE PERFORMED: <br /> 'NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING # 0 OVER-BORE. DIAMETER <br /> %%WELL # EIC—l . 'P I M4 tj aPRESSURE GROUT <br /> p *Other �' GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICA ONS <br /> 0 MONITORING HOLLOW STEM DIA. OF BOREHOLE�j_P, ULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS�o TYPE OF CASING: 0 STEEL ( PVC 0 OTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL .; SIS lay TREMIE TYPE TO BE USED: '(AUGERS 0 HOSE <br /> 0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT) GROUT SEAL PUMPED: 0 Yes 0 No (NOTE : MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS POCilayta +, 4 rOA I / 11 <br /> 0 OTHER:_0 OTHER APPROX. BORING DEPTH �S� '3� 0 BOLTD TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if 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 Ordinances, Rules and ylations, d all applicable Californian State Laws. <br /> Signed x Title/Company (`leoWlrj7t <br /> IQ <br /> Print Name OY1V10.. Date `�/ '" <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : <br /> WORK PLAN DATED : A <br /> Application Accepted By ` ` (/ Date Issued <br /> —WL�2 ', 1005 Area <br /> Grout Inspection By _ Date Final Inspection By U Date <br /> Destruction Inspection By Dale <br /> COMMENTS / CONDITIONS: <br /> i <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC' D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> Wei 00 350 2 �q QJ SR# 32 4 <br /> C-57 WC -WAIVER. C-57 Letter of Autho Izati o sign permit_ Encroachment doc_ <br /> EHD 29-02-001 <br /> 622/04 <br />