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San Joaquin County `~ <br /> a Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgoorii/ehd UNIT IV <br /> NOS JUL 2 b PM 4: 17 <br /> FORWell Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE , a "'` `COUNT Y <br /> VIROHHENTAL <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work deddrFbklcL lrhls[)@P(N"rf)1 Q'pft in compliance with San <br /> ,Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 1 1 Assessors <br /> WELL Location O 5 7 5, (ttsQa� Cross Street ._IJe•1 hl City�_�IZYN Zipqf�Parcel# <br /> PROPERTY <br /> Owner clILaj(i9 YA Address `�E,���7 S. L 11)a(" City G Y\ZipgS20k- Phone# 3.2 � 60 <br /> s�Ug <br /> C-57 Contractor Vl(g=j;4q 1�CAl►Vt' Address CISO I�W C D'C City Z0-9195 3Lic#to�7c-khone# � <br /> Consultant/Sub Cntr �(S1E Address SIAr,JJ V—A City_' �Lic#LZ0a- - Phone#� ��(�7 -16Z <br /> GIS Coordinates:X —'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> XNEW WELL/ BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> jrWELL#f :X I U l — 0 PRESSURE GROUT <br /> 0`Other ~—T GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING HOLLOW STEM DIA.OF BOREHOLE1f Q' 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:gr,—y�r <br /> `*EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS -�:,o \ CtO TYPE OF CASING: 0 STEEL XVC 0 OTHER: <br /> `VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL"?�_—TREMIE TYPE TO BE USED: 0 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 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS C kc <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH I 3 BOLT D 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 Regulations, and all applicable California State Laws. t- <br /> Signed x ��- Title/Company � <br /> Print Name Date -7 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted ByL 0� Date Issued Area <br /> Grout Inspection By ate Final Inspection By Date _ <br /> Destruction Inspection By 67 Dat <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> X01:3 a $q. ou 22JJ SR# <br /> C-57 WC -WAIVER C-57 Letter of Autho zoti o sign permit_Encroachment doc <br /> EHD 29-02-001 <br /> &n')Ina <br />