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W Ysan Joaquin County b- r lr ill <br /> Environmental Health Department r � SITE 3 <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA92(l <br /> MITIGATION <br /> • °• (209)468-3449 Fax: (209)468-3433 Web: 'I o�r_org/eh�l QQ�. UNIT IV <br /> Well Permit Application 1'5. !!Tr ,=-���,���� <br /> 4 . <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED— <br /> Application is hereby made to San Joaquin County for a pernlf to construct and/or install 11.6e work desa'ibed. 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 /> _ ��I <br /> Assessors. <br /> wELL Location t i) fe-r 1U'rl_ Gross street L City �flr C f lip�fS aU Farce <br /> PROPERTY L-Ou i-s ; Wt tC��rCis <br /> Owner fk=0C- _Address V163,ll_C, _City 5 -ten <br /> ((,Ck Zip 5020 Phone# <br /> C #' r t a 3i3 ` <br /> C W Contractor Address qSUiA�- eM(� City y`' L'hvIC..Z.Zip { 5✓'Lic#ff S1b Phone# 5 �� <br /> Consu t/SubCntr D 1F1'C 'Address�Dt 'I - _CitY�ic# phone#1�cxi)522` 11 IIGi <br /> GIS Coordinates:XY - - Townshl flange Section <br /> MRI(TO BE PERFORMED: <br /> p NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,'OTHEW) pESTRUCTION (choose type below) <br /> 0 SOIL BORING# -- I]OVER-BORE.; DIAMETER . . <br /> �}WELL# )PRESSURE GROUT s <br /> 0`Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> 7YEL2f_ML L INSTALLATION TY_PJ� CONSTR igno SPECIFIC <br /> >s <br /> MONITORING I]HOLLOW STEM DIA.OF BOREHOLE', aMULTIPi_E CASINGS 0 MULTI LEVEL WELL CASING DIA: <br /> l]EXTRACTION ]]AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 Sl'EEL Q PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: p AUGERS Q HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP'or CPT)GROUT SEAL PUMPED: 0 Yes a No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS._... .. - . '. .. <br /> 0 OTHER: n OTHER__. APPROX. BORING DEPTH0- �-�� -- - (]BOLTED TRAFFIC BOX or STOVE PIPE . . <br /> CONDUC OR CASING PROPOSED (if YES,1ist'specifications In comment sedan) <br /> COMMENTS: Yd�� � �. �� � ' k <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 Ordi c s and latlons,and all applicable California State Laws. : <br /> Signed x Tdte/Company <br /> Print Name AMC Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: tl <br /> WORK PLAN DATED' ,? <br /> Application Aocepted By r r v Date Issued01,1101-. � L,� Area <br /> Grout Inspection By Date Final'Insgectlon By <br /> (4;4` Date <br /> Destruction Inspection By Date <br />€ COMMENTS f CONDITIONS: " <br />!: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D,BY.` DATE PERMIT/SERVICE REQUEST#. INVOICE <br /> 0 . 00 01--h$+ q zz SR# Lts Z'p 3 <br /> C-57— WC--WAIVER C-57 Letter of Auth 120 ion o sign Wmit—Encroachment doc <br /> EHD 29-02-MI <br /> 6/22104 <br />