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UWErSan Joaquin County <br /> MMQ11 <br /> tnmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> *ro Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 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 Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location ads Nr (qMYvA- 5}, Cross Street AH4aV AV( City,- CIZ-IrOQ Zip Pamel# /39-320-13 <br /> PROPERTY <br /> Owner C"r/t5 6kobra jr_ Address 9997E r �— zipWW- Phone# �06- -26 7 <br /> C-57 Contractor(AWqA 3,flSi'I-V AddressctSD HgWp_ Q4 City.w.L2ZipASULic#LgL*lPhonea(&EI33 <br /> -5 <br /> 800 <br /> Consuant/SubCntrAAUdWCtd <br /> (Lf &IV Address 937 Sha. y ad Cily.9lac fl Lic# Phone# <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ANEW WELL/ RING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION (choose type below) <br /> 0 SOIL <br /> Ba <br /> 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> Other' r/tt�6 GROUT SPECIFICATIONS <br /> COMMENTS: �/` ) CPT— <br /> TYPE <br /> PT-TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ''� <br /> 0 MONITORING p HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: `` L� <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS_TYPE OF CASING: 0 STEEL 0 PVC p OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 6/lrrRl/- TREMIE TYPE TO BE USED: ]]AUGERS 0 HOSE <br /> p AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORIF 0 HAND AUGER GROUT SPECIFICATIONS X/t&, O <br /> OTHER: l'yr 0 OTHER APPROX.BORING DEPTH ?a S Ae�4t- 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED -41j*_(ff 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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, <br /> Rules and Regulations,and all applicable California State Laws. 1 <br /> Signed _1 t' V—t'—L 11� Title/Compan <br /> I <br /> Print Name 2)Of lel koQ I w,"c Date I2 JB�DQ- <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 36 9 Mor tli C ra it f rS 1"ree,� <br /> WORK PLAN DATED`:/ O c4 t) 1i 2,Y 2"�0//. 20/14 <br /> Application Accepted 8 _ V i c�o r t a M�S.Q�'+n e U Date Issued 2 Area ! S <br /> Grout Inspection Byy_L Yj -4 DateDal 2 Inspection By • ��( (jOate /Z'/g•0 S/ <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: S CPT- <br /> ACCOUNTING ONLY: AID# FACS <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKS REC'O BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 350 ► 89. 00 $9. 00 SR# oa40G2S <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD 29.02-001 <br /> 622104 <br />