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,y gip, <br /> San Joaquin County <br /> Environmental �iealth 1}eparttm� moo SITE <br /> 304 East Weber Avenue, 3rd Floor,Stockton,CA� �S` O MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.s,)gov.��l 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 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location'Z3\S N. l D O c o-do St' Cross Street �`S lR CityS�ocX q>� Zip °15z oy Parcel#Assessors l�S -I 0'z) <br /> - 11 <br /> PROPERTY '` <br /> Owner S offer Ugl�ec�1� Address b L3 L t"ler,e-f (J,� CityS�tocic fi4,� Z1p"LO-I Phone# L\)°t-IV\)CM <br /> '1 <br /> C-57 Contractor\4 0`a ��\\=� Address-Q O �' f_��a_ City 5t-�r� Zip�56 1 Li� � -1-1 7 100Phone#� <br /> ons;ulta /S Cntr_ e�\oo��c9�—`fie cJh�.��'Address L 1 fil, St City o o Lio# — Phone#Z­Q`1 S- -Lq l\ <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE EERFORMED: <br /> Q NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) D DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> a WELL# S7_ �t mac,w _-2 0 PRESSURE GROUT <br /> 0*tither GROUT SPECIFICATIONS-_.._. <br /> COMMENTS: S sty Q�--k <br /> I=QF WELL INSTALLATIOhl JXPE COt AMU_CTION SPECIFICATIONS <br /> 0 MONITORING (I HOLLOW STEM DIA.OF BOREHOLE,,,,_,_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL VVELL CASING DIA: _ <br /> 1I EXTRACTION 0 AIR HAMMER/DRWEN CASING THICKNESS_TYPE OF CASING: 0 STEEL D PVC D OTHER: <br /> 11 VAPOR 13 MUD ROTARY DEPTH OF GROUT SEAL 2,'- S-ova TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING l]HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: fl OTHER--­ APPROX.BORING DEPTH 1 r ID BOLTED TRAFFIC BOX or a 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 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordina ales nd g tions,and all applicable California State Laws, <br /> Signed x Title/Company_Q., l W 2 L C� e-&k <br /> Print Name `��h rad �0��rti��-' Date 29 , <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED" <br /> ApplicationffJM `` J11V / ����`�Sc' <br /> pP cepted BY Date Issued ��/�-/J Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection Date <br /> COMMENTS/CONDITIONS: <br /> EACCOUNTING ONLY: AID# FAC* <br /> S FEEfNFOAMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> g9.ov S°l.o itv 13 <br /> .01)1 &M z I at, <br /> C-57— WC:•WAIVER C-57 Letter of Autho azatia o sig pertnit--Encroachment doc <br /> EHD 29-02-001 <br /> 6/22104 <br />