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San Joaquin County <br /> Environmental Health Department 5iTE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: vvww.sjgov.org/ehd UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES t 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 Tltie,Chapter 911115.3 and the Standards of San Joaquin County Environmental HAalth Department <br /> WELL Location 615sa r' �Ly p-o Cross Street Clty.au mpl Zip 915 Pasroel*ors <br /> PROPERTYL`LV &7AOOwner Address,2911 r <br /> AW R, Gity�Zip�Pho�n/e* <br /> C-57 Contractor /� /� �l *Mdress 55'b t Rv_ City��Q2AZlp� �Llal�7 tPhone#�?);1�'H300 <br /> Consultant I Sub Cntr Arc /' 9Qf.Vt� Addresa f ll Lh&��,'••1; City�_Lic# Phone#a0���-.?oW <br /> GIB Coordina":X Y Township 0141 Range Section <br /> 1MO55 TO O[P"WORMED: <br /> III NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER,) p DESTRUCTION (Choose type below) <br /> a SOIL BOR G r OVER-BORE DIAMETER <br /> I WELL* r2 AIIJ A 0 PRESSURE GROUT <br /> 0'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE <br /> I MONITORING I HOLLOW STEM DIA.OF BOREHOLE-&_- p MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA aa"_ <br /> Il EXTRACTION n AIR HAMMER/DRIVEN CASING THICKNESS_TYPE OF CASING, o STEEL a PVC o OTHER: <br /> $VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALj.11 10' TREMIE TYPE TO BE USED. p AUGERS a HOSE <br /> V AiR 3PAAG J 07-ONG tJ F06H rvii4 i (yr 4LAL rUM1`rU E Yea U NO IPIV I C. IM AAIMUM t-KGG-CALL UCl I M IS 30') <br /> b SOIL BORING a HAND AUGER GROUT SPECIFICATIONS &QA;r <br /> 0 OTHER-._a OTHER - APPROX.BORING DEPTH- <br /> lye BOLTED TRAFFIC SQX 0; 3 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED 1,.1 0 (lf 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 /> : hereby certify that I have prepared this application and that the work will be done in accordance with Son Joaquin <br /> County Ordinances, Rules and Regulations,and all applicable California State Laws. <br /> Signed x TltlelCompany ✓GGi t w vLs/1 lic 1 ( � �� <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,AD-DR 88: (0ma S 4b L V� <br /> WORK PLAN DATED: 3 q <br /> Application Accepted By Date Issued- <br /> Grout <br /> ss Grout in"ction ey Date6 5 Flnal Inspection By r d Date l a <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: �- <br /> ACCOUNTING ONLY. AIDII FACS <br /> LES FEE INFO AMOUNT REMITTED CHECK s REC'D BY DATE PERMIT/SERVICE REQUEST t INVOICE <br /> -T 3 G I o5S SR;k 43(0'8 0 <br /> C-57_ WC--WAIVER C-57 Letter of Authorization to sign permit--, Encroachment doe <br /> EM 29.02.001 <br /> 6/22104 <br /> Z0 3!DVd Div O1S3Q014 SZZZ-GLS-60Z Sb :ZT S00Z/SZ/80 <br />