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San Joaquin County � <br /> .- Environmental Health Department SITE <br /> � <br /> 304 East Weber Avenue 3rd Floor Stockton, CA 95202-, � � � MITIGATION I <br /> (209)468-3449 Fax: (209)468-3433 Web: www.s /e <br /> jgov-or ltd <br /> i <br /> c cfFoR�'`� Well Permit A lication `� � ��.�� �� �' ZQUNIT IV <br /> � <br /> pP at,,ouiP4 rcmiTY <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE I95�1 VIROt�j�F� <br /> Application is hereby made to San Joaquin County for a permit td construct andfor install the work desyr>ItT�ej�.�T]iId� ani Is'rli8&JTn compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location 6r40V+1t6Ue D / Assessors r <br /> JAI f/Crros�s/Street t- U1� City r�C Zip 7l'176 Parcel# ] 1 y <br /> f V a IrO� 2'T liter V a f l�,l t r- i / <br /> PROPERTY �, / LA� „S._� I L e- <br /> Owner - V+ <br /> / ,,- f] ress r rk" j City ip Phone# <br /> C�57 Contractor__li+w F+Ft l�t Address `�%!'T44 � City ��� � Z, 15-611 l ic#/7�Clcy hone# '��P��?`�r�"q(to <br /> C6nsultant/Sub Cntr /eft41A:-F Id It s_ Address. ASF ]�r k City �f�cfllar✓Lic# Phone# 20 gY$ ' 3 SIS <br /> I <br /> GIS Coordinates:X 'Y Township + Range Section <br /> WORK TO BE PERFORMED: I <br /> p NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') � DESTRUCTION (choose type below) <br /> p SOIL BORING# i OVER-BORE, DIAMETER I." M05-d)3 <br /> p WELL# I PRESSURE GROUT <br /> p"Othsr GROUT SPECIFICATIONS 1yr3q�C'eHcrro'r- 1 UJS-1.3 s <br /> COMMENTS: <br /> 4 <br /> I <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING p HOLLOW STEM DIA.OF BOREHOLE []MULTIPLE CASINGS p MULTI-LEVEL WELL CASING DIA: <br /> p EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: []STEEL PVC p OTHER: <br /> p VAPOR p MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: p AUGERS. []HOSE <br /> p AIR SPARGE!OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 19Yes g No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> p SOIL BORING p HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER: p OTHER APPROX.BORING DEPTH ISS 11v35 p BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) 1 <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 Ibe done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations,and gall applicable California State Laws. <br /> J <br /> Signed x Title/Company ��7'r[�,•'O{ /�l (�I�Tf (��� <br /> Print Name is Pa N Date <br /> } <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: '33–S Gr-A,174t'a..i OC4 ra <br /> WORK PLAN DATED: 230LO5 . <br /> Application Accepted By Date Issued /c� !� Area C <br /> Grout Inspection By U Date inal Inspection By Date <br /> Destruction Inspection ByDate 11.2 <br /> h <br /> COMMENTS f CONDITIONS: 6 <br /> F <br /> ACCOUNTING ONLY: AID# FAC# <br /> r <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> i <br /> a�a� CCS6 C� /�7s 7�7 /ay�� sR# yS5 7 <br /> C-57_ WC -WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD 29-02-001 <br /> 6122104 <br /> I <br />