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Q San Joaquin County -- <br /> Environmental Health Department a <br /> w 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 , }s MITIGATION <br /> (209}468-3449 Fax: (209)46$-3433 Web v�%ww.sjgay.arg/ehd UNIT IV <br /> Well Permit Application ;�Lt�rtr,_+ Ivrf <br /> mON-REFUNDABLE PERIW EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permitto construct and/or install the worts described. This application is made in compliancewu.h San <br /> Joaquin County Development Title,Chapter 0-111115,3 and the Standards of San Joaquin County Environmental Health Department: E <br /> .`• Assessors <br /> WELL Location �Je2 s Cross Street t/J. L�71 city ' K_ zip�4?arrel#_I S _- 25C� a� <br /> OwnePROPr Y ,l�t,� Address. 5.7 W- C s oc k zl �C ne# <br /> Owner �[u1`�Y7C1y P I.rJ� Ptso <br />` C S7 GontractorLL—t Qa �l k V1,C AddressqSG �C<AY City t tr4fW?Z Z{p� 15`3 L1 �1$51IOSPttanei�C�f�S <br /> �- <br /> ntaultant! ubCnfr O i ddress Il(�l_��"'. CftyI��Q5A ice — Phone � C1t J -Lft'�aj <br /> Township___ " Ra 'I Section <br /> G15 Coordinates:X_ — .,Y,_ p___.__ -Range <br /> WORK TO IBE PERFORMEu: � <br /> a NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNICH,BAND AUGER,OTHER'} ,�ESTRUCTIQN i (choose type below) <br /> 0 SOIL BORING# VER-BORE.'.DIAMETER <br /> a WELL a PRESSURE GROUT <br /> B"Other GROUT SPEGIFIGA71ON5__._ <br /> COMMENTS: I <br /> YELL INSTALLATIg=Eg C0KSM1j0TIONSPEL-IFICA71ONS <br /> ONITORLNG n HOLLOW STEM DIA.OF BOREHOLE _ MULTIPLE CASINGS 11 MULTI-LEVEL WELL CASING DIA: <br /> p EXTRACTION U AIR HAMMER/DRIVEN CASING THICKNESS I F TYPE OF CASING: 0 STEEL. p PVC 11 OTHER: <br /> [I VAPOR II MUD ROTARY DEPTH OF GROUT SEAL: TREMIE TYPE TO BE USED' a AUGERS Q!HOSE <br /> a AfR SPARGFJ OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes Q No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS ' <br /> a OTHER: _,p OTHER _ APPROX.BORING DEPTH: �i ---___--. .- �BOLTED TRAFFIC BOX or a STOVE PIPE <br /> �9� CONDUCTOR ASING PROPOSED (if YES,rst Spedfic6tfons In comment section) <br /> COMMEFiTS: I� W {� r ;;I:. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMIT$. <br /> 4.8 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS., <br /> I hereby certify that I have prepared this application and that the work will be dans in accordance with Sart Joaquin <br /> CoutntyO les an gulations,and all applicable Cal forth State Laws, <br /> Signed x + TdierGompart 162 <br /> Print Narita <br /> DEPARTMENT USE ONLY <br /> SITE MAIC IN UNIT IV FILE,ADDRESS: � <br /> WORK PLAN DATED. t: <br /> Application Accepted ByDate Issued ! 2A a <br /> Grout Inspection By Da#e' Final Inspection By 7 4ate <br /> pestnrction ins action B Date + <br /> COMMENTS!CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> Pic CODES FEE INFO AMOUNT REMITTED CHECK# REC'D6Y 1 DATE PERMIT!SERVICE REQUEST# INIIOICE <br /> 0 2 p. 0� 1 az SR# Zoe <br /> C-57 WC -WAVIER C-57 Letter of Author ati n o:9i n permit Encroachlinent doc,� <br /> EHD 2M2-ool <br /> 6aZV4 <br />