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• Is F l Ij C01PY <br /> a San Joaquin County- <br /> Environmental <br /> ounty Environmental Health DepartmentSITE <br /> i 304 East Weber Avenue, 3rd Floor. Swckton CA 95202 1 / MITIGATION <br /> Y (209)468-3444 Faux; ('309)468-3433 Web: vvww.sjgov.or24'elr I !U UNIT IV <br /> r, *' Well Permit Application - - <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED `- <br /> Application is hereby made to San Joaquin County for a permit to construct andfor Install the work desGdoed. This appdcr mon is made in eompoanw with San <br /> Joaquin County DevelOpro0ot Title,Chapter&1115.3 and the Standards of San Joaquin County Emironnenlal Health Department <br /> 1 Assessors <br /> WELL Location f'3G1C: 5i t�-'1` 4 Cross Street HVIj` ASLIry a3DLr-it> zip 5' x1'sParc .t# f-OZ+:,^'Cr; <br /> PROPERTY <br /> Otwipr -it/yr..r('7Lc.%srt A.durass�' ' dXit'+� _Grty Sjy_c FA'! Zip Phone# , ' ;;1 ' <br /> C-57 contractor ills f' rNu+,T/rAddrass fAc n'irN sra<atrr C:i[yjt,-.z� Zip,2L.'l Uc*jki'`�.Prmnoz,ZG`T-fiJ2- cE'� <br /> Consultant r Sub CnlrIl,yr+',.:r> .;.e *fc- Address 2£7SG. et�ykN'w'7 City s,*o-+ar-J <br /> GIS Coordinates:X /o3Pi1&/- L5" ,Y c r(,`fi0'33 3 " ,Township Range_Section /r% <br /> E PERFORMED: <br /> EW WELL I SORlNG (GPT.GEOPROBE.HYDROPUNCH.Ii-AND-AUGER.OTHER') U DESTRUCTION (choose type below) <br /> 0 SOIL BORING# R OVER-BORE. DtAMITER <br /> 06W- LLA_3�y,}�,=,s - PRESSURE GROUT <br /> a'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL IN TA_t„_AT1ON TYPE CONSTRUCTION SPECIFIGATIONB r, <br /> MONITORING KHOLLOV;STEM DIA.Of BOREHOLE 0 MULTIPLE CASINGS Q MULTI-LFVEL f1ELL CASING OIA: <br /> 0 EXTRACTION 0 AIR HAMMER,ORIVEN CASING THICKNESS Sit 4g TYPE OF CASING. 0 STEEL PVC p OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL jt7< TREMIE TYPE TO BE USED: GAUGERS 11 HOSE <br /> 0 AIR SPARGE!OZONE 0 PUSH POINT(GP or CPT)GROU T SEAL.PUMPED. WYes U No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING 0HA140AUGER GROUT SPECIFICATIONS f i n»" c a � e (SIL � a+.�'/ <br /> 11 OTHER:_0 OTHER -- -. APPRJX. BORING DEPTH q 5 _[)BOLTED TRAFFIC BOX or STOVE PIPE <br /> CONDUCTOR CASING PROPOSED. (If 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 Iprepa this application and that the work will be done in accordance with San Joaquin <br /> County Orditri les egulations,and all applicable California State Laws. <br /> Signed x_ f a TitlefCampany S. ? .s. <br /> Print Name iiatA Date ^ E y/v 4- <br /> DEPARTMENT USE ONLY <br /> H H <br /> SITE MAP IN UNIT IV FILE, ADDRESS: e^ <br /> _ 29.65 8%WQ 1r <br /> WORK PLAN DATED: ^ D^ ZOO /1 p <br /> .Application Accepted By Date issued <br /> Groul Inspection By Dale � �_-�Flnal lospaotion BY . . Date <br /> Destruction inspection By Dale <br /> COMMENTS J CONDITIONS: <br /> ACCOUNTING ONLY. AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED. CHECO# REC'D BY DATE PERMIT!SERVICE REOUEST INVOICE <br /> o 1 / <br /> spit <br /> 11 <br /> C-57 WC_-WAIVER_ G57 Letter of Authorisation to sign p Amit_Encrptcchhrncrtt�doc— <br />