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03/09/2086 14:27 2094683433 <br /> EHD PAGE 02 <br /> San Joaquin County . <br /> Environmental Health, Department SITE <br /> m - 304 East Weber Avenue,3rd Floor, Stockton,CA 95242 <br /> MITIGATION <br /> (209)468.3449 Fax:(209)468-3433 Web: www.sjgov.org/ehd UNIT 1V <br /> F Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 7 YEAR FRAM DATE ISSUED <br /> 4pplication.15.hereby made to.San Joaquin.County.for a permit to construct andlor instalithe work described. This application is mads In complianne with San. <br /> Joaquin County Development Title,Chapter 9-1115.3 and.the Standards of San Joaquin County Environmental Health Department- <br /> Asses <br /> epartment- <br /> WELLLocation JY000 E 1Kwy R Cross Street..Cry -city �e � Zip Y6-.Z P rceisrs ��-{ <br /> � R�._-� <br /> PROPERTXT ! A <br /> Owner. 11 ime- 04 CO. Address X737 W „Carr��lrK�occa� S'e'a, WA zip 9�191phone# ate-.2PS}-2100 <br /> C-5T contractor ' ✓�d' I[!,4 Address 9 0QiJ.°,l�-a Clly `n tZp�tIWSSy'Licfa! 5f�i5pane# ^S�QO <br /> Consultant/subcnir t4-14— ASJOI--� Address 130 Z='t'lv4 S. City 01-,A-U6ff. Phone# -770 o,9o7 <br /> GIS.Coordinates:X Y ,Township Range 5ectipn <br /> WORK"13E PERFORMt=v � <br /> Q NEW WELL t BORING...(OPT,GEOPROGE,HYDROPUNCH,HANQAUGER,OTHER*) DESTRUCTION. .(choose type below) <br /> U SOIL BORING.# [I OVER-BORE. .1)IAMETE2„ <br /> a WELL# RESSUKEGFROUT <br /> p•other. GROUT SPECIFICATIONS CAT gA-� <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SF�CIF_ICATION5 <br /> MONITORING }(HOLLOW STEM. {r DIA.Or BOREHOLE n MULTIPLE CASINGS U MULTI-LEVEL. WELLCASING DIA-'�� L <br /> El EXTRACTION /a AIR HAMMtERIDRIVEN CASING.THICKNESS-- TYPE ORCASING: D-STEEL l)PVC Q OTHER: <br /> IAPCIti B MUD ROTARY DEPTH OF GROUT SEAL _ TREMIE.TYPI_TG BE USED; q.AUrpERS [I HOSE <br /> Q AIR SPARGE.OZONE 0 PUSH POINT(GP.or CPT)OPOUT SEAL PUMPED;.. a Yes .-`p No (NOTE:.MAXIMUM FREE-FALL DEPTH IS 301.) <br /> ly SOIL BORING. p HAND AUGER GROUT SPECIFICATIONS <br /> Q OTHER_a OTHER .APPROX,BORING.DEPTH n BOLTED.TRAFFIC BOX or 0 STOVE.PIPE <br /> CONDUCTOR CASING PROPOSED (f 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 Sari Joaquirt <br /> County Ordinanqps,Rules and Regulations,and all applicable.California State.Laws. <br /> aignea X TISiOIGorn a C�`r/1�o/rMG��_ 1�fcyr <br /> Print Narne /�l/V4 7 y�/ �Ox1' Date' 3T7/o6 <br /> DEPARTMENT USE ONLY <br /> SITE-MAP.IN,UNIT IV FILE,ADDRESS: <br /> WORK PLAN.DATED: <br /> Application Accepted.g]' ,�ss1C�-, Date Issued ��,-_�?7 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction lnspeaiion By Date1 <br /> COMMENTS 1 CONDITIONS: C"ti S&U LOP <br /> i <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK* REC'D BY DATE PERMIT/SERVICE REQUEST# IKVOIeE <br /> e,57 WC -WATVEP-- C-57 Letter of Authorization to sign permit„E=ncroachment doc__ <br /> Bd-ID 29-02-001 <br /> 6/32104 <br />