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i an Joaquin County4L nm <br /> w ' ® Envir menta'Z.Health.Depa"rtment <br /> East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> -,7:P0'468-3449 Fax: 209 468-3433 Web: www.s ov.or /chd UNIT IV I <br /> ( ) g <br /> Well Permit Application '' n <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r <br /> Application Ust}� r edo Sir rin County for a permit to construct andlor instal]the work described. This application is made incompliance with San <br /> Joaquin Count Cm e2n{j'Ce• a ter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Joaq Corrii._.. J� .+ P <br /> „ ., <br /> 2 C.� >�vnt O i� t! Assessors <br /> Parcel# 141—u <br /> WELL Location Z e Cross Street � 7T� City Zip 9�� �Q� <br /> PROPE TY. <br /> Owner t STEPkR. `t fddress *G .City. w► Zip i'L53APhone# ' 4 �g J�0 <br /> C-57 Contractor Ats r ci0 ess i.��'` I City] Zip f_jNLic#jI OPhone 30 :4?—U <br /> pp�� �,� ,,1 Ct�� , �r'Jc <br /> Consultant 1--VFA tF�+ ��� L Address: w� City 61� f�# �q-Phone#(-114-*9 <br /> //�� 21 ( 1 <br /> .Zc .: ;Township Section 1 1V' r7 3 1 <br /> GIS Coordinates:X 31. 94 ,Y CRange_ <br /> WORK TO BE PERFORMED: <br /> NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION (choose type be€ow) <br /> SOIL BORING# Itt 'OVER-BORE.' DIAMETER=_ <br /> 1�0'ther <br /> LL# PRESSURE GROUT <br /> !� J GROUT SPECIFICATIONS <br /> COS: <br /> i <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING D HOLLOW STEM - DIA. OF,BOREHOLE D MULTIPLE CASINGS a MULTI-LEVEL WELL`.CASING DIA:------ <br /> a <br /> _-___a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS tTYPE OF CASING: a STEEL PVC a OTHER: <br /> I<M <br /> VAPOR a MUD ROTARY DEPTH OF GROUT SEA*Ys <br /> TRIE TYPE TO BE USED: a AUGERS' HOSE <br /> i a AIR SPARGEI OZONE PUSH POINT.(GP or CPT)'GROUT SEAL PUMPEDNo (N TE: MAXIMUM FREE-FALL DEP <br /> 0 SOIL_BORING y a HAND AUGER GROUT.SPECIFICATIONS �,,,,,�,otu.�e eaF vo <br /> t� <br /> OTHER:H trAlli W OTHER U989 ?LOK r APPROX. BORING DEPTH' _ff.BOLTED TRA FIC BOX or, []STOVE PIPE <br /> CONDUCTOR CASING PROPOSEb (if YES, list specifications in comment section) <br /> F <br /> COMMENTS: ' <br /> A <br />{ NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />! 48 WORKING HOURS',NOTICE REQUIRED FOR INSPECTIONS. <br /> t I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinance and Regulations, and ail applicable California Stat Laws. i <br /> 9 rte` <br />� Signed x �7itlelCompany <br /> Print Name r�- ;< .Date <br /> j DEPARTMENT USE ONLY <br /> c SITE MAP 1N UNIT IV FILE,ADDRES `L J <br /> . WORK PLAN DATED: <br />} Application Accepted By Date Issued �_ t Area <br /> Grout Inspection By Date ” ` Final Inspection By Date 5• "� <br /> i Destruction Inspection By Dale <br /> COMMENTS 1 CONDITIONS: <br /> i ACCOUNTING ONLY; AID# FAC# } <br /> 1 PE CODES FEE INFO AMOUNT REMITTED CHECK# RID BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> '].3v SR#0550 1Z... <br /> C-57_ WG -WAIVER C-57 Letter of Authorisation to sign permit Ericroachment doc N <br /> EHD29-02-001 WEB a. <br /> 9l1112DO7 <br />