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FILE COPY <br /> an Joaquin County 1. .. <br /> Jak 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.sjgov.org/ehd UNIT IV <br /> Well Permit Application <br /> q 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 Titre,Chapter&1115.3 and the Standards of <br /> San <br /> LJoaquin <br /> �County Environmental Health//Deep�paar2rtmernt. ors -f <br /> WELLLocation 5C) it P. Il. cross street ll•`JI.+�of Aldty _zip "2✓J7lOP� `7 37003 017 <br /> PROPERTY 77c�;� p ..yycl I' /s <br /> owner Jennl$ lUX)flsrinrYAdd1.2z8�ZN•(goltunnINCi1V 'V (nk6A1t.ZipN5?)5-3Phone# 209- sg6 58 <br /> Cs7 contractor fe-6' I, linq Address23lP5Wio10(Un Df- City 00-+m Zip 5 05(jc#63638 Phone#27x1 •C7�IZ j <br /> ``..,,� <br /> Consultant/Sub Cntrjy(( V10n p +al A4dress23115E. 4ftA troJyPc ._ lc# 65150( Phone#,ZV2 833'058 <br /> 2 qhC t. <br /> GIS Coordinates:X 3l• ,Y Z(• 14 Township Range Section <br /> WORK TO BE PERFORMED: r <br /> a NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) `KbESTRUCTION (rhoos belay) <br /> 0 SOIL BORING i< - OVER-BORE. DIAMETER ' S CC(ed (,p <br /> XWELL# MiA L I -11, yl 4 40•d-Ey Wla)S A'd.11 Mu:-7 MW`S,h)wir RESSURE GROUT wt <br /> 0 Other >G;OUT SPECIFICATIONS QeX jAidtt rICS v <br /> COMMENTS._Ij'ZGU3:ZJ 4 fre 49o�GeLF., r .. D7Ya.rti �1vrt� GF �Leadee <br /> ✓ W <br /> �,. <br /> TYPE EL <br /> E OF WL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ?MONITORING 'j 0 HOLLOW STEM DIA OF BOREHOLE_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> g EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING U STEEL g PVC O OTHER: \ <br /> 0 VAPOR g MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Q AUGERS 0 HOSE <br /> g AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 97Yes 8 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') \ <br /> g SOIL BORING a HAND AUGER GROUT SPECIFICATIONS j <br /> 0 OTHER: A OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE /I <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 /> 1 hereby certify that I'have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordina R I,and egula(ions,and all applicable Callifomtp State Laws. 1 f <br /> Signed r e/Coman �JJr�ldfl'1T '\VrIQh��Y,��fonrnCn�aQSe.(VICeS,�^' <br /> PriMNameJoNn L�4r)C'\ I Date -7— <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: NG A4b J Q <br /> Application Accepted By :. _ - Date Issued__ <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By + - Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: NDA -FAC# <br /> PE CODES FEE INFO ! AMOUNT REMITTED CHECK# /REC..'ID BY I DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc. <br /> ElVO4 of-XOt DPL A* / J <br /> FILE COT <br />