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man Joaquin County <br /> k;..?�w V�vironmental Health Department SITE <br /> { 7�n� 600 E.Main Street, Stockton, CA.95202-3029 MITIGATION <br /> 17 (` 0 468-3449-Fax: (209)468-3433 Web:www.sjgoV.org/ehd UNIT IV <br /> Q ixQ . i HEALTH Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES'I 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 Sari Joaquin County Environmental Health Department. <br /> sessors <br /> V <br /> WELL Location Tf3L)5 I I Yb6y, .Sk 2 - Cross Street City mb kA w. .__ _Zip _Parcel# S- 2d S <br /># PROPOTY <br /> 1 pwner'lPnnr�Pulrril4n 9ra;wteo.l!bo._Address"p�� 1�1y� City Y Zip 11 Phone# <br /> C-b7 Contractor 1 Address City,Ranfsitf.�rdcstiip _Lic#'It7S1D _Phone# �9t(t��L3$�1i1c9- <br /> Coni lSub Grit r t*Inc Address S)jQfU fZCC[d CVty _Lic#Wopa`t .- _Phone#{2rt9)90`!-l6b_ _ <br /> GIs Coordinates:X Y ,Township Range Secti6n <br /> WORK TO BE PERFORMED: <br /> *NEW WELL!BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /># <br /> Q <br /> OVER-BORE. DIAMETER <br /> 11 SOIL BORING# <br /> ICWELL#, RW- - 0 PRESSURE GROUT <br /> A`Other GROUT SPECIFICATIONS . <br /> " I <br /> COMMENTS: l <br />= TYPE OF WELL INSTALLATION nPE CONSTRUCTION SPECIFICATIONS <br /> VMONITORING ;B(HOLLOW STEM DIA.OF BOREHOLE]j. MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> j]EXTRACTION AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: a STEEL `JPVC in OTHER: <br /> r, <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 4'AndOlk" _TREMIE TYPE TO BE USED: D AUGERS 0 HOSE <br /> p AIR SPARGEI OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED:. n Yes S'No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS e <br /> = a OTHER: . . p OTHER APPROX.BORINGiDEPTH.9S'�9$=Oirld 35'jkBbLTED TRAFFIC BOX or D.STOVE PIPE <br /> CONDUCTOR CASING PROPOSED WO - (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 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Or}Jinanc , Rules and.Re fations,"and all applicable California State Laws. <br /> Signed x Title/Company v UirWtlrle Inc. <br /> ! Print Name'�jnb� WMTA, Date 0111-1/02 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �b z. <br /> WORK PLAN DATED: "Yl- - M 2..0o7 �1G� <br /> Application Accepted 6 ✓�°"v` Date Issued . Area'F -2 — <br /> Grout Inspection By . Date Final Inspection By Date <br /> + Destruction Inspection By Date <br /> t COMMENTS 1 CONDITIONS: D P Sa <br /> F <br /> ACCOUNTING ONLY: Al D# <br /> FAC# <br /> s PE CODES FEE INFO AMOUNT REMITTED CHECK# REC=D-BY DATE PERMIT I SERVICE REQUEST# 1NV016E <br /> SR# <br /> xi Z11196 <br /> a C-57_ WCC WAIVER— C-57 Letter of Authorization to sign permif�__Encroachment doc_ <br /> f EHD 29-02-001wcb <br /> 6122104 Lf` <br />